Ethical Billing: Misunderstanding vs Fraud

Michele Silcox, CMRS, consultant
ABA Therapy Billing and Insurance Services & MKS Consulting LLC

When faced with an ethical billing uncertainty, there are variations of issues to analyze.  Is the error related to a misunderstanding or truly an intent to commit fraud?  The overwhelming number of individuals and organizations I have worked with truly are operating under misunderstanding of ethical billing practices and seek to actively modify policies and increase knowledge and training surrounding ethical billing.  On occasion, discussion is not met with the ability to create meaningful change and an individual must decide to leave an organization to find a better match.

Listed below are some definitions of health insurance fraud and potential consequences followed by discussion of common misunderstanding and suggestions for remediation.


Wikipedia defines Insurance fraud in part as “any act committed to defraud an insurance process when a claimant attempts to obtain some benefit or advantage they are not entitled to.”

Health insurance fraud is an intentional misrepresentation on an insurance claim that results in reimbursement.  Some examples could be submitting claims for services not rendered, unbundling services (billing for activities that are included in another code) , upcoding (billing for a higher level of service), altering claims submission to not appropriately match the service rendered, or providing services by a non-qualified service provider.

The False Claims Act (FCA) is the federal law that imposes liability on individuals and companies who defraud governmental programs.

A whistleblower is a person who exposes information that is deemed illegal or unethical within a private or public organization.


The best way to beat misunderstanding is through using reliable, relevant resources in health insurance claims submission.  The ABA Coding Coalition at has provided resources regarding the billing codes used for adaptive behavior services for submitting claims for reimbursement from health insurance plans.

  1. Ethical billing questions often come down to a misunderstanding of the intent of the codes as well as a misunderstanding of the implementation of the codes by each payer. It’s imperative that the full intent of the codes is understood by all employees who are responsible for rendering or billing services.  In addition to this step, each payer policy must be reviewed to seek understanding of a payer who has made an independent decision in the use of the codes and periodically reviewed for changes.
  • For example, the intent of the codes for treatment and direction are to be billed concurrent as individual services; however, some payers are still disallowing this activity. A health insurance company who has established this policy and shared in their documentation or through training can take a stand that if this policy is violated, it could be considered fraudulent billing.
  1. Adaptive behavior services codes are bundled codes which equates to pre and post activities for a face-to-face activity code reimbursed only with the time rendered face-to-face and the rate received for that service time. Unbundling during billing could be considered fraudulent billing.
  2. Each payer has a policy for what constitutes a qualified health care professional to render services. In addition, in-network organizations have payer requirements of approved credentialing for each of the provider levels in order to submit claims for reimbursement.  These can be found through payer policies or communication with provider representatives. Submitting claims under a different provider who is credentialed when a non-credentialed provider renders the service could be considered fraudulent billing.
  3. The location of services is part of the authorization approval process and session notes should represent the actual location where services are rendered, and claims should appropriately match the session note. Changing a location in order to receive reimbursement could be considered fraudulent billing.

These are just a few examples to emphasize the importance of education and training in any area that is related to ethical billing practices.  It’s important to implement a voluntary internal compliance program to test the standards you put in place and avoid drift in your processes.  Linked below is the Office of Inspector General guide for a compliance program for individual and small group practices.

It is my hope that through active communication regarding health insurance reimbursement and continued education and training, the scope of this issue can be narrowed, and individuals and organizations can stay out of harm’s way for fraudulent activity.