Organisations billing government or regulated payors operate under rules where documentation failures become fraud allegations.
Coding and documentation. The record must support the level and nature of service billed. Upcoding, unbundling of services that should be billed together, and billing for services not documented are the recurring theories.
Medical necessity or its analogue in other contexts is a substantive condition of payment, and disputes over it are increasingly characterised as falsity rather than as coverage disagreements.
Referral and kickback restrictions. Statutes prohibit remuneration to induce referrals, with safe harbours that must be satisfied element by element. Compensation arrangements with referral sources should be at fair market value, commercially reasonable, and not varying with volume or value of referrals.
Overpayment obligations. Identified overpayments must be reported and returned within a statutory period, and retention converts a billing error into a false claim. Identified generally means when the entity has, or should have through reasonable diligence, determined that an overpayment was received and quantified it.
Self-disclosure protocols exist with defined benefits, including reduced multipliers and suspension of the return clock during the process.
Controls that matter. Prepayment review sampling, periodic external audits under privilege, a functioning compliance hotline, and prompt investigation of coding variances.