Undercoding

LilMissCoder

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I have a doctor that is not on board with the rest of us. He states that undercoding is not as serious as overcoding and you cannot be penalized for undercoding. He is now wanting actual documention of a case where a provider was penalized for undercoding. Does anyone have any documention of this that you would be willing to share? If not, any help in pointing me in the right direction would be great. Thanks in advance for you help.
Tracy
 

mitchellde

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I have always read that you can be penalized for undercoding because it is still a fraudulent submission, and it violates the false claims act. So I would start the seach there, that is so a search using key words false claims act and work it from there.
 

crystallena

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As a former fraud investigator, and a current compliance auditor, I can tell you that intentionally undercoding a service IS considered fraud. Undercoding can create an unfair market advantage. Honestly, as a consumer, wouldn't you choose the less pricier option? Also, when CMS or OIG (and many private thrid party payers) are conducting audits, they pick samples to audit. Whether or not they proceed with a full-scale audit depends on the error rate within that sample. If only 10 records are selected for audit, and 8 of them turn out to be undercoded, the provider automatically has an error rate of 80%. The physician may then be responsible for the cost of an IRO (Independent Review Organization) or could face other penalties. Some good places to get information about fraud are oig.hhs.gov (Office of Inspector General) and NHCAA.org (National Health Care Anti-Fraud Association.)
 
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Does anyone have more recent documentation/guidelines/articles that I can look at? I currently have a provider who thinks the same way.....

Thanx!
 

drtomgrant

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couldn't get to these links, can you verify and repost?

couldn't get to these links, can you verify and repost?
 
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