URMC Compliance Program Policy Manual:
Billing and Claims

When claiming payment for services, all providers in the System have an obligation to their patients, third party payers, and the state and federal governments to exercise diligence, care, and integrity. The right to bill the Medicare and Medicaid programs, conferred through the award of a provider or supplier number, carries a responsibility that may not be abused. URMC is committed to maintaining the accuracy of every claim. Many people, throughout the System have responsibility for entering charges, diagnoses and procedure codes. Each of these individuals is expected to monitor compliance with applicable billing rules and established coding guidelines. Any false, inaccurate, or questionable claims should be reported immediately to a supervisor or to the Compliance Officer.

False billing is a serious offense. Medicare and Medicaid rules prohibit knowingly and willfully making or causing to be made any false statement or representation of a material fact in an application for benefits or payment. Furthermore, federal law states that it is also unlawful to conceal or fail to disclose the occurrence of an event affecting a health care provider's right to payment with the intent to secure payment that is not due. Examples of false claims include, but are not limited to:

  • Claiming reimbursement for services that have not been rendered
  • Filing duplicate claims
  • "Upcoding" to more complex procedures
  • Including inappropriate or inaccurate costs on cost reports
  • Falsely indicating that a particular health care professional attended a procedure
  • Billing for a length of stay beyond what is medically necessary
  • Billing for services for items that are not medically necessary
  • Failing to provide medically necessary services or items
  • Billing excessive charges.

Those who prepare or submit claims should be alerted for these and other errors. It is important to remember that outside consultants only advise the provider. The final decision on billing questions rests with the provider.

In compliance with federal law, the URMC entities do not permit charging for any Medicaid service at a rate higher than that approved by the state or accepting any payment as a precondition of admitting a Medicaid patient.

The URMC entities carefully follow the Medicare rules on assignment and reassignment of billing rights. If there is any question whether an entity or facility may bill for a particular service, either on behalf of a physician or on its own behalf, the question should be directed to a senior billing or finance supervisor, who may consult with the Compliance Officer. Special care should be taken in reviewing claims prepared by entities outside the System, and personnel should request documentation from outside entities if necessary to verify the accuracy of the claims.

A health care provider or supplier who violates the false claims rules is guilty of a felony, and may be subject to fines of up to $25,000 per offense, imprisonment for up to ten years, or both. Legislation enacted in 1996 extends the reach of federal criminal penalties to false claims submitted not only to Medicare and Medicaid, but to any health care benefit program, including private third party payers. Other persons guilty of false claims may face fines of up to $10,000 per offense, imprisonment for up to one year, or both. In addition to the criminal penalties, the Federal False Claims Act permits substantial civil monetary penalties against any person who submits false claims. The Act provides a penalty of triple damages as well as fines up to $10,000 for each false claim submitted. The person (as well as the facility employer) may be excluded from participating in the Medicare and Medicaid programs. Violations of the assignment and reassignment rules are misdemeanors carrying fines of up to $2,000 and imprisonment of up to six months, or both. State statutes impose similar criminal and civil penalties for false and deceitful conduct in connection with billing.

Numerous other federal and state laws prohibit false statements or inadequate disclosure to the government and mandate exclusion from the Medicare and Medicaid programs upon conviction. For instance, it is impermissible to make, or induce others to make, false statements in connection with a provider's Medicare certification. Persons doing so are guilty of a felony and may be subject to fines of up to $25,000 and imprisonment for up to five years. A facility or individual health care providers will be excluded from the Medicare and Medicaid programs for at least five years if convicted of a Medicare- or Medicaid-related crime relating to patient abuse. Medicare and Medicaid exclusion may result if a facility or a provider is convicted of fraud, theft, embezzlement, or other financial misconduct in connection with any government-financed program.

It is illegal to make any false statement to the federal government, including statements on Medicare or Medicaid claim forms. It is illegal to use the U.S. mail in a scheme to defraud the government. Any agreement between two or more people to submit false claims may be prosecuted as a conspiracy to defraud the government.

URMC promotes full compliance with each of the relevant laws by maintaining a strict policy of ethics, integrity, and accuracy in all its financial dealings. Each employee and professional who is involved in submitting charges, preparing claims, billing, and documenting services is expected to maintain the highest standards of personal, professional, and institutional responsibility.