How to Identify and Prevent Medical Billing Fraud: A Short Guide

medical billing fraud

Medical billing fraud happens across the nation every day. It takes a long time to catch fraud, and healthcare fraud costs taxpayers and private agencies millions yearly.

Fortunately, there are ways to identify and prevent medical billing fraud and abuse in your business. Make sure that you report fraud as soon as you find it, no matter how much or how long ago it was. That is the best way to protect yourself from liability.

The Four Types of Medical Billing Fraud

There are four main types of medical billing fraud that insurance providers and medical practices experience: excessive billing, upcoding, falsified records, and billing for unnecessary treatment. We’ll cover how to identify and prevent these types of fraud.

Excessive Billing

It is sometimes easier for a medical professional to bill treatments or appointments separately. Sometimes they bill too many times for these treatments.

This is the most straightforward fraud to catch since insurance companies can compare bills against treatment schedules to find discrepancies. To keep this from happening, ensure you aren’t double-billing for an appointment or treatment.


Upcoding is when a practitioner assigns diagnostic codes for severe conditions to patients without those conditions. This often happens because the medical professional has an outdated list of medical codes or lacks an understanding of medical coding.

Ensure you always have the most up-to-date code list available to prevent medical billing fraud. Additionally, assign this task to someone in your business who best understands medical coding.

Falsified Records

Falsifying records happens when a medical professional submits a claim to an insurance provider without supplying medical records to prove the need for treatment. Usually, this occurs when practitioners try to cover errors in their treatment notes.

Always make sure you document treatment properly and take plenty of notes. In addition, make sure you accurately submit records when submitting a claim to insurance, which will help keep you from having falsified documents.

Unnecessary Treatment

This fraud happens when practitioners perform treatment patients don’t need or charge them for treatment they never received. It often happens because of switched medical records or poor organization. Protect yourself from this type of fraud by keeping records organized.

Prevent Fraud and Other Violations

The best way to stop fraud is to catch it before it happens. Setting up checkpoints for different people during the billing process can help catch errors before the bill ever gets to the client or their health insurance.

PracticeForces offers secure medical billing assistance to medical practices across the nation. Hiring our medical billing company is an excellent step toward preventing medical billing fraud and improving HIPAA compliance. Call us today at (727) 499-0351 to ask about our services.

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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