New Column Shares Physician’s Perspective on Fraud, Waste and Abuse

Humana has a commitment to detect, report and prevent fraud, waste and abuse. We rely on contracted physicians, other health care professionals and business partners to support this commitment.

While errors may not be intentional, they still have negative systemic effects leading to vital resource losses needed to provide care for individuals within the health care delivery system. Also, excessive charges can prevent patients from seeking needed treatment or filling prescriptions.

During my years of practice, I’ve seen several instances of waste and abuse that were not the result of malicious intent, but were created through shortcuts in documentation and/or a single episodic coding and billing error, such as:

  • Billing for services not rendered.
  • Billing for services at a frequency that indicates the physician is an outlier as compared with his/her peers.
  • Billing for services that are performed by another physician.
  • Billing a health insurance payer using a CPT code for a more expensive service than was performed (upcoding).
  • Misusing modifiers, e.g., modifiers 25 and 59.
  • Billing for the component parts of a medical procedure when a single code is available that includes the complete procedure (unbundling).
  • Billing for more units than rendered.
  • Lacking documentation in the records to support the services billed.

Some physicians find themselves being evaluated for fraud, waste or abuse. Humana is required by state and federal laws to report activities of concern. While physicians and other contracted health care professionals may feel nervous about an investigation, many investigations result in reasonable justification of the physician’s actions. The importance of appropriate documentation and billing cannot be overstated.

To learn more about Humana’s efforts to combat fraud, waste and abuse, including available, confidential and anonymous reporting methods, visit Humana.com/fraud.

Sincerely,

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Kristine Bordenave, M.D., FACP, CPMA Corporate Medical Director