Page 31 - C.Journal 3rd edition

Claims Journal 3rd Edition Claims Journal 3rd Edition

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- Unbundling: it is the improper submission of separate claims for services that should be
billed together as one combined service. By unbundling, the provider receives more in total
Provider Fraud and Abuse fees than he would have received had the claims been properly submitted as one.

- Fraudulent Diagnoses and Unnecessary Services just to justify unnecessary services.

Here we would like to talk little bit about Health Care Fraud, most probably about provider - Fraudulent Dates of Service: a 20 percent coinsurance payment is not required for certain
fraud and abuse services provided to patients within the three-day period prior to hospitalization. A hospital
Provider fraud is the most prevalent and costly type of health care fraud. This is because dis- may intentionally misrepresent the date of a service, stating that it was provided within the
honest providers understand the health care system and are well three-day window when it was not.
positioned to take advantage of it.

- Overutilization: sometimes a provider performs and bills for a service that is not medically
necessary, but the provider believes in good faith that the service is in fact necessary. In such
Some Types of Provider Fraud cases, the provider is not engaging in fraud, but rather overutilization, the most common
form of health care abuse.

- False Claims: it is occurs when a provider submits a claim for This is just a small part of one kind of health care fraud
medical services provided to an insured when in fact he/she did not This course was advised by Dr. Elsayed Mubarak, -thank you Dr.-, and he is welcoming everyone
perform such services.
who needs to ask about fraud, beside if anyone wants a copy of this course, it is available with us
and also with Dr. Mubarak.
- Billing Schemes: in these schemes, a provider actually performs the service
he/she submits a claim for, but by improperly billing for the service he/she
fraudulently obtains a higher payment than he/she is entitled to.
Anyone is most welcomed to share his story or experience with us.

- Up Coding: in up coding , a provider submitting a bill does not use the correct code for the
service actually provided. Instead, he uses a code for a similar or
related service that is more expensive.

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