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Thread: Medicare Fraud?!?!?!?!

  1. #1
    Join Date
    Apr 2007

    Default Medicare Fraud?!?!?!?!

    AAPC: Back to School
    My office wants me to hold all of our Medicare claims for the month of January. I asked the reason for this and I was told that we hold them so that they can meet their deductible with other physicians, and so we will not loose that money (beacuse our patients are not going to pay us.) Is this legal? I got my CPC about 10 months ago and I am just kinda scared to do this. Please advise!!!

  2. #2
    Join Date
    Apr 2007
    Frederick, MD


    Medicare gives providers one year to file claims. Once the procedure is performed it is okay at any point to submit a claim as long as you do so within a year of the date of service.

  3. #3
    Join Date
    Apr 2007
    Kansas City, MO


    It is not fraud.
    It is not illegal.

    We put stuff on hold all the time for various reasons...as long as you submit by the timely filing cut-off. Other offices do this.

    Just remember it will may affect any monthly billing reports (lower billed charges and reciepts for Jan)

  4. #4


    As it is true providers are given one year to file claims with Medicare, I do not think it is ethical to hold all Medicare claims for one month just so 'patients deductibles can be met by other physicians'. As an employee for a billing service we are contracted to process claims for our providers on a daily basis, and when we don't we are to document why the claim is being entered at a later date. I realize you may not work for a billing service, but directly under the physician, claims should still be processed in a timely manner. As a professional coder, we are held to the highest standards set forth by AAPC and should follow the code of ethics in order to provide the best service possible for the employers, clients and patients.

  5. #5
    Join Date
    Apr 2007
    Greeley, Colorado


    We are holding our Medicare claims until the fee schedule is published. But we do that only because we do not accept assignment, so we need to know what the limiting fee is. That is the only reason we have ever held Medicare claims.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Join Date
    Apr 2007
    Lubbock, TX


    I agree with knorman - although it's not illegal, the reason behind it doesn't seem ethical, but that's just my opinion, which doesn't count for much.

    The plan may not work out all that well, anyways. One month may not be enough time to rack up $250 (I think that's how much it is now...) in Medicare allowables from other providers for a majority of patients. But I'm just guessing on that.

  7. #7
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    For a small practice where collecting copays and deductibles can be daunting, it might make sense to hold the claims. It's not 'wrong', and it certainly is a fiscal strategy to insure eventual payment fram CMS, rather than having to chase the patient.

    The only issue I see with this is that your days in AR will surge. If you're ok with that, you have a year to get the claim to them.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  8. #8
    Join Date
    Apr 2007
    White Plains, NY


    I'm a fraud investigator.

    This is not an illegal practice.

    Lin Osborn

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