“I never suspected it—until my billing portal flagged a routine flu shot with seven units of CPT code 99214. That’s how I learned that small coding errors can mean huge compliance risk.”
It started with a single flag. Just one line item, buried in hundreds of claims that week. As a busy physician managing both patients and paperwork, it felt like a fluke. But that tiny anomaly triggered a cascade—an internal review, an uncomfortable conversation with my billing team, and the realization that even our best intentions couldn’t protect us from the complexities of modern reimbursement.
Today, medical billing fraud and abuse is a growing crisis. It’s not always driven by bad actors. In fact, more often it comes from a combination of inadequate training, ambiguous rules, and high-pressure revenue goals. The consequences, however, are severe. We're seeing:
$60 billion annually in improper Medicare payments (OIG)
DOJ crackdowns on small clinics, not just large systems
Expanding audits of telehealth, upcoding, and phantom billing
This article brings together expert insight, real-world advice, and battle-tested tactics to help every medical professional stay compliant—and stay in business.
Tips & Tactical Advice
Before we dive into the tactics, let’s get real: billing fraud and abuse prevention isn’t just a compliance checkbox—it’s a survival skill. For small clinics, independent physicians, and startup practices, a single misstep can spiral into audits, clawbacks, and reputational damage. What follows isn’t theory. These are field-tested practices from clinicians and compliance pros who’ve been through the fire—and emerged smarter.
✅ Know the Difference Between Fraud, Waste, and Abuse
Fraud is willful deception—like billing for a service that was never rendered.
Waste means overuse or inefficient processes.
Abuse involves stretching guidelines or misusing billing codes without malicious intent.
Tactical Tip: Create a billing dictionary tailored to your practice. Define common CPT codes and clarify their proper usage. Cross-train staff so no one operates in a vacuum.
✅ Conduct a Proactive Audit
Audit 5–10% of charts monthly, focusing on high-frequency codes. Validate documentation of time, services, and modifiers.
Tactical Tip: Pair clinicians with non-clinical auditors for balance. Use red-flag indicators like frequent 99214/99215 usage.
✅ Use Coding Authorizations and Dual Review
Require secondary sign-off on claims over $500 or those with high-level E/M codes.
Tactical Tip: Build dual-signature review into EHR workflows for real-time oversight.
✅ Technology Safeguards
Smart billing integrations in EHRs offer real-time flagging and coding support. Activate audit trails to track edits.
Tactical Tip: Configure guardrails like alerts when visit time doesn’t match billing level.
✅ Encourage Self-Reporting
Create a reporting tool for staff to flag:
Duplicate billing
Altered notes
Requests to inflate codes
Tactical Tip: Foster a culture where error reporting is rewarded, not punished.
✅ Document Forensic-Grade Proof
Include start/stop times, patient consent, modality (for telehealth), and reason for high-level codes.
Tactical Tip: Use customizable macros to prompt documentation completeness without over-automation.
✅ Monitor Regulatory Changes
New rules affect telehealth, time-based billing, and service location coding.
Tactical Tip: Assign quarterly research rotation. Have staff present rule updates to the team.
✅ Build a Culture of Compliance
View compliance as patient protection. Normalize peer review, celebrate proactive self-corrections.
Tactical Tip: Begin each week with a short story highlighting a compliance success.
Expert Opinions
Dr. Emily Ho, MD, MPH, Compliance Director
Dr. Ho leads audit strategy for a major health network and advises rural clinics on CMS compliance best practices.
“Our audit rate dropped 40% after differentiating audio-only versus video consults. Training was our best investment.”
John Reynolds, CPC, Coding Consultant
A certified professional coder with 15+ years in payer-side fraud investigations and clinic-side training programs.
“Upcoding isn’t always malicious—but it’s always dangerous. Internal audit by outlier thresholds is non-negotiable.”
Laura Kim, JD, Healthcare Attorney
Legal counsel to medical groups navigating whistleblower cases, CMS self-disclosure, and federal investigations.
“The DOJ’s focus on small clinics shows you don’t need intent to be liable. Preventive audits are protection, not paranoia.”
Real-World Case Study
Case: Oakland Pediatrics
Billed 99214 for visits that lacked extended counseling documentation. Found during internal review after payer denials.
Actions:
Re-coded 30 claims and refunded $4,800
Filed CMS self-disclosure
Added EHR flags and policy for dual sign-off on high-level codes
Outcome:
Avoided potential $1.2M audit liability
Improved compliance culture and payer trust
Rethink "Best Practices"
National benchmarks are helpful but not definitive. Your population might warrant higher levels of care or longer visits.
Tactical Tip: Track your own patterns and code use. If a provider consistently outpaces others, review their documentation.
Sharing Failures
We once discovered our EHR defaulted to 99215 after certain documentation triggers—no matter the complexity or time.
Result: Refunds of $12,400, one corrective disclosure, and one priceless lesson: Never trust a shortcut with your license.
FAQ
Q: Can I get in trouble for honest mistakes?
A: Yes, under civil fraud laws. Intent isn’t required for penalties.
Q: Who should audit small clinics?
A: Staff members can lead reviews with help from external consultants.
Q: What’s the safest way to document telehealth?
A: Include consent, duration, location, and modality. Use appropriate modifiers.
Q: How often should I run audits?
A: Monthly for high-frequency codes; quarterly for full reviews.
Call to Action
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Be part of something bigger. Engage with the community. Get on board. Jump in. Raise your hand. Be the change.
Lend your voice. Take the first step. Start here. Make your move. Ignite your momentum. Take action today.
Claim your spot. Let’s do this. Start learning. Build your knowledge base. Explore the insights. Have your say.
Contribute your ideas. Share your voice. Help shape the future. Be a thought leader. Support the mission.
Fuel your growth. Unlock your next level.
References
CMS Telehealth Billing Audit Report (June 2025)
While the full audit report isn't directly available, the June 2025 MedPAC Report to Congress includes detailed analysis of Medicare payment systems, including telehealth billing practices. You can also review CMS’s Telehealth & Remote Patient Monitoring guide and HHS’s telehealth policy updates for current billing policies and flexibilities extended through September 2025.DOJ Enforcement Priorities Memo (June 2025)
The DOJ Civil Division’s memo, issued June 11, 2025, outlines enforcement priorities under the Trump administration, including a focus on billing investigations involving small medical groups and civil rights-related fraud. You can read the full memo summary in the National Law Review article.HHS OIG 2024 Report on Improper Payments
CMS’s Fiscal Year 2024 Improper Payments Fact Sheet reports an estimated $31.7 billion in improper Medicare Fee-for-Service payments, largely due to insufficient documentation and upcoding. For a broader federal perspective, the GAO’s FY 2024 improper payments report estimates $162 billion in total improper payments across agencies.– $60B in improper Medicare payments due to upcoding and missing documentation.
Read the OIG summary
About the Author
Dr. Daniel Cham is a physician and medical consultant with expertise in medical technology, healthcare management, and medical billing. He focuses on delivering practical insights that help professionals navigate complex challenges at the intersection of healthcare and medical practice.
Connect with Dr. Cham on LinkedIn to learn more: linkedin.com/in/daniel-cham-md-669036285
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