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What Cardiologists Should Know About Medicare Fraud Prosecutions

December 10, 2023

What Cardiologists Should Know About Medicare Fraud


Medicare fraud is a big issue that cardiologists need to be aware of. With complex billing rules and regulations, it can be easy to accidentally overbill Medicare or improperly code for services. While most doctors strive to do the right thing, cardiologists are among the specialties most targeted for audits and investigations into fraudulent activities.

This article provides an overview into common Medicare fraud issues cardiologists face, laws and penalties around Medicare fraud, and key things cardiologists can do to protect themselves and stay compliant. I know all these rules can feel overwhelming – but being informed is the best defense against mistakes or false allegations.

Common Types of Medicare Fraud by Cardiologists

Some of the most frequent types of Medicare fraud that cardiologists face allegations around include:

Upcoding – When you bill for more complex or expensive services than were actually delivered. Like billing for a level 5 office visit when only a level 3 was warranted.

Unbundling – Breaking what should be one billing code into multiple lesser codes to increase payment.

Medically Unnecessary Services – Billing tests, procedures, or other services that are not needed per clinical standards. Stuff ordered primarily for financial gain.

Kickbacks & Self Referrals – Receiving money or other perks to refer patients to a specific hospital, lab, etc.

Relevant Laws & Penalties

Allegations of Medicare fraud are typically prosecuted under the Federal Anti-Kickback Statute and False Claims Act. Penalties can include:

– Treble damages – Having to repay 3 times the amount falsely billed
– Exclusion from Medicare/Medicaid programs
– Imprisonment
– Fines up to $250,000 per false claim

Even just a Medicare audit can be extremely costly and time consuming to deal with. Healthcare fraud often results in massive settlements – like the $2.3 billion paid in 2022 by medical testing lab Quest Diagnostics.

How Cardiologists Can Protect Themselves

The threat of Medicare fraud investigations creates a tense environment for cardiologists. Here are some proactive things you can do to help avoid problems:

Carefully document reasons for ordering tests, procedures, services in patient medical records. Demonstrate medical necessity.

See patients directly tied to services you bill. Don’t just sign off on plans mid-levels implemented.

– Have an experienced medical billing company handle your claims and coding. Errors can lead to fraud allegations.

– Perform regular audits on your charts and billing activities to catch any issues early.

– Stay up-to-date on Medicare billing policies as they frequently change. What was ok before may now be considered fraudulent.

– Be careful of referrals. Only send patients to facilities you truly believe provide best care for reasons not tied to personal financial interests.

I know that’s a lot of complex information to digest! The main thing is to realize Medicare fraud is a big deal▋

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