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ED Coding and Reimbursement Alert

Reasons to Avoid Sloppy or Inaccurate Coding

Published on Sun Jun 01, 2003

There's nothing better than a list of consequences to whip any coder into shape. You may not be a bad seed, but potential penalties for fraudulent coding should encourage you to make extra careful selections.

CMS and HHS' Office of the Inspector General will go after you the coder and your practice for systematic patterns of fraudulent coding and billing that include improper unbundling, bundling and upcoding. (See "Avoid the Red: Understand Your Liability as a Coder".)

The types of penalties you could incur for egregiously and repetitively violating coding guidelines include but are not limited to the following, offered by Jason R. Levine, JD, a consultant and senior editor for Murer Publications at Murer Consultants Inc., a legal-based healthcare management consulting firm in Joliet, Ill:

  • Fines for violating the federal and state False Claims Act, "the primary civil enforcement vehicle" the government uses to combat Medicare abuse. Knowingly presenting a false claim to the government evokes a civil penalty between $5,000 and $10,000 in addition to three times the damages incurred by the government with your false claims. Deliberate ignorance or acting in reckless disregard of the truth or falsity of claim information can also land you in hot water.
  • Penalties and fines for violating provisions of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA has enacted the penalty of exclusion from the Medicare and Medicaid program if you are convicted of a felony related to healthcare fraud. Under HIPAA, you can also incur fines in addition to what you would receive for violating the False Claims Act.

  • Qui-tam actions. The False Claims Act has a provision that allows private parties to sue on behalf of the government to recover damages, which are often whistleblower suits. Common whistleblowers are employees, former or disgruntled employees, or other people with some kind of relationship to the practice, such as a supplier or contractor.

  • Criminal penalties usually brought under the Medicare, Medicaid Fraud and Abuse Statute. For coders who qualify as people who made false statements or representations in connection with false claims, that means a possible one year in jail and a fine of up to $10,000 or both. Physicians may incur steeper penalties.

     

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