One of the ways the Medicare program and other payer plans are recovering overpayments and identifying billing fraud is through the regular use of data mining.  Simply put, by utilizing software programs that monitor and compare billing and coding data, enforcement authorities are easily able to identify problematic trends in physician billing.  This is an extremely cost effective means of identifying outliers since it does not require a person to manually review claims.

Many physicians I have spoken with over the years mistakenly believe that if they undercode their services, they are reducing their risk of being audited.  However, with data mining programs, this is unlikely to be the case and in fact the opporits may be true.  This is because many of these programs utilize comparative peer data to determine whether a physician’s patterns are outside of peer group norms.  Therefore, a physician who consistently bills one level of evaluation and management service, for example, could very well be flagged for audit if his or her peers routinely bill varying levels of service.

One good way to evaluate whether your coding patterns fall within norms is to request your peer group data from your Medicare Area Contractor and see how your own coding patterns match up.

Finally, if you still think Medicare isn’t paying attention to your coding, consider this case recently reported by the Chicago Tribune: Mobile Doctors CEO, Physician Charged With Medicare Fraud