Are You Performing Periodic Documentation, Coding, and Billing Audits?


The government continues to actively enforce the False Claims Act [31 U.S.C. §§ 3729-3733] (FCA) which states that “it is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.”  Examples of this include filing claims that are not medically necessary, billing for services not rendered, billing for a service at a higher level than actually performed (upcoding), etc.

The Department of Justice (DOJ) news release describes the $1.85M settlement reached with a Georgia provider group (Aarti D. Pandya, M.D. P.C.) where the provider:

  • Performed procedures on patients who did not qualify for the procedure (sometimes causing harm to the patient)
  • Falsely diagnosed patients with glaucoma in order to bill for other unnecessary services and tests
  • Tests were not performed correctly and sometimes performed on a broken machine
  • Documentation in the medical record was incomplete/inaccurate

The case was initiated by a former employee of the group under the qui tam/whistleblower provisions of the FCA.  The government intervened in the lawsuit in 2018.  Read the DOJ’s news release here.

The key to avoiding unnecessary exposure is to perform periodic documentation/coding/billing audits.  This can be performed by certified coding/auditing professions, either internally or through an external company.  Contact The Honest Approach if you’d like to find out more about our documentation/coding/billing audit services.