Jul 22, 2025
Written By Elizabeth Cifers
Fraud and abuse in medical billing aren’t always about bad actors or deliberate wrongdoing. Sometimes, it’s about small mistakes that add up, like billing without adequate documentation, using the wrong code or modifier. Unfortunately, even unintentional errors can lead to serious consequences, especially in specialties like retina, where services are frequent and high-cost. Understanding what counts as fraud or abuse, and how to avoid both, is one of the smartest things a practice can do to protect itself from audits, penalties, and reputational damage.
Fraud usually involves intentional deception, such as knowingly billing for something that wasn’t done. Abuse, on the other hand, may be unintentional but still results in improper payments or the overuse of services. Both are taken seriously by payers and regulators, and both can lead to audits, fines, or worse if it isn’t addressed.
There is an old saying in the billing and auditing world: not documented, not done, especially in the eye of an auditor. Every billed service needs to be clearly supported in the medical record. What does that mean? No vague statements, no copy-paste without updates, and no missing rationale. The more specific your notes, the better your claims will hold up under review.
Using modifiers or higher-level codes without appropriate and supportive documentation is one of the most common ways practices run into trouble. Maybe a visit level is bumped up “just in case,” or a modifier is added to get a test paid separately. Either way, if it’s not supported, it’s risky. The physician(s) are rolling the dice that they won’t get caught, and it is becoming riskier every day. The penalties for a false claim, which means knowingly submitting or causing a submission, start at $13,946 per claim. It’s better to be paid accurately and keep the money than to be overpaid, audited later, and face possible significant fines.
An internal review process, whether conducted monthly, quarterly, or annually, can help identify trends or minor errors before they escalate into larger issues. Furthermore, enlisting a retina-savvy external auditor every year or two provides an additional layer of protection. Detecting problems on your terms is always preferable to having a payer uncover them first. You can’t fix what you don’t know is broken.
Fraud and abuse prevention isn’t just about the billers. Everyone, including the front desk, clinical staff, and physicians, plays a role in ensuring the services are documented and billed correctly. Ongoing training, clear communication, and a shared understanding of compliance expectations go a long way in keeping your practice on track and showing you have a living, breathing compliance program.
Preventing fraud and abuse in medical billing doesn’t mean running a perfect practice, but it does mean running a mindful one. The best way to avoid trouble is to stay informed, organized, and proactive. With regular audits, supportive documentation, and a well-trained team, your practice will be better equipped to handle scrutiny, avoid costly mistakes, and keep delivering great care without interruption.
Worried that small billing errors could turn into big compliance risks? Fraud and abuse prevention begins with awareness and continues with action. I assist retina practices in identifying vulnerabilities, enhancing documentation, and applying practical compliance strategies that safeguard revenue and reputation. Let’s connect to discuss how a proactive audit or team training can help your practice stay ahead of payer scrutiny. Schedule a free 30-minute consultation with Elizabeth here.
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