Online Medical Billing Programs – Fraud and Abuse

Fraud and Abuse are the things that every medical biller wants to steer clear from in the industry. As a professional, you must understand the difference between them and the consequences for violations.

Fraud is an intentional deception that one makes.  Abuse is involves actions that are not usually accepted within the industry.  Fraud and abuse is costly to the healthcare industry and violations for such are met with heavy consequences.  A medical biller or coder is responsible for understanding and maintaining professional, ethical, and moral conduct when it comes to processing claims and dealing with protected health information.

Online Medical Billing Programs – Fraud and Abuse

Examples of fraud include the following:

  • Accepting bribes
  • Changing claims to increase reimbursement
  • Billing for supplies not provided.
  • Entering false ID #s on the claim to get reimbursement
  • Falsifying record to gain reimbursement.


Consequences of Fraud include the following:

  • Administrative penalties
  • Monetary penalties
  • Exclusion from Medicare or other health plans.
  • Criminal sanctions


Examples of abuse include the following:

  • Billing non-covered procedures as covered.
  • Claim errors
  • Billing for charges in duplicate
  • Charging excessively for services or supplies
  • Improper billing to wrong payer
  • Submitting claims when medical necessity has not been met.
  • Violating provider agreements.

Consequences of fraud include the following:

  • Referral for medical review, audits
  • Recoupment of paid funds
  • Written warnings.

To avoid fraud and abuse it is important for a practice to review the OIG work plan each year to see the areas being scrutinized. It is also important to have practice management guidelines in place to avoid violations. Every practice should have a compliance officer who is designated to enforce proper practice standards. Having periodic internal audits is a good way to identify areas of possible fraud and abuse and to correct them internally.

A professional medical biller or coder has an ethical responsibility to adhere to proper and accepted practice standards and guidelines.


By: Dawn Moreno, PhD, CBCS, CMAA, MTC. Dawn lives in the beautiful Southwest and has been a medical coding and billing instructor for over 7 years. Her joy is teaching adults new career skills. .  Interested in quality medical billing training?   Check out Online Medical Billing Course

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