Medical Auditing Practice Exam

What is it called when a provider submits a claim for an evaluation and management service using a different date of service to circumvent bundling rules?

1. Overbilling

2. Fraud

3. Misrepresentation

4. Billing abuse

The correct answer is: Fraud

The scenario described involves a provider submitting a claim for an evaluation and management service using a different date of service specifically to evade bundling rules, which is considered a serious violation of billing practices. This action falls under the definition of fraud because it entails intentional deception for the purpose of financial gain or benefit. In healthcare billing, fraud always implies a knowing misuse of information or submission of false information with the intent to deceive. When a provider knowingly alters information, such as the date of service, to obtain reimbursement that would not otherwise be permissible, it demonstrates a clear intent to defraud the payer, be it an insurance company or a government program like Medicare. Other terms like overbilling, misrepresentation, and billing abuse could apply in different contexts, but they do not capture the full essence of intentional deceptive practices aimed at achieving an undeserved financial advantage, which is central to the concept of fraud in medical billing. Therefore, this understanding is crucial for distinguishing the severity and implications of various billing irregularities.