Billing Compliance Risk Areas

Objective

To assist members of the CUIMC community in preventing the submission of erroneous claims or engaging in unlawful conduct involving Federal and State health care programs.

Risk Areas

The Office of the Inspector General ("OIG")and Office of Medicaid Inspector General ("OMIG") are responsible for protecting the integrity of Federal and State health care programs, including Medicare and Medicaid. To help health care providers prevent erroneous or unlawful claims for payment by these programs, the OIG and OMIG have identified risk areas where providers may be vulnerable to fraud and abuse. Such risk areas for physician practices include, among others:

• Unbundling of services (billing for multiple components of a service that must be included in a single fee);
• Billing for services not rendered or not provided as claimed;
• Billing for non-covered services as if covered;
• Submitting claims for items or services that are not reasonable and necessary;
• Coding using one or two middle levels of service codes exclusively (also known as “clustering”);
• Up-coding the level of service provided;
• Knowing misuse of provider identification numbers;
• Double billing resulting in duplicate payment; and
• Failure to properly use modifiers.

CUIMC clinicians and staff shall not engage in such practices, which may result in serious consequences for the practitioner and the University, including monetary penalties, exclusion from Federal health care programs, and, under certain circumstances, criminal penalties.

Office for Billing Compliance
Policy#: OFBC 1008
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024