How federal fraud and abuse laws are changing

The False Claims Act has the potential to trip up healthcare medical coders, even if a false claim goes undetected.

The act imposes liability and possibly litigation on persons or companies that defraud the federal government. In the eyes of the government, it doesn’t matter if a false claim inadvertently gets through. “You don’t need intent to get in trouble,” says Catrena Smith, coding manager at KIWI-TEK, a medical coding firm in Indianapolis. “You could still be held liable.”

At an educational session during the AHIMA Convention & Exhibit in September, Smith will present updates on how fraud and abuse regulatory changes are impacting medical record coding in ambulatory care practices.

Five laws govern much of the compliance requirements imposed on physicians, she’ll tell attendees, each with examples of how these laws, whether purposeful or accidental, are violating the law. They include the False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law, Social Security Act and the United States Criminal Code.



Coders, Smith says, are a first line of defense against fraud, and surprisingly new coders can fulfill that important role because many have just come out of training and lack extensive experience.

But the new coders might be hesitant, and Smith implores them to not be. “New coders may not say something if a claim doesn’t seem right, so research it,” she counsels. “The coder may not know if the claim is appropriate, so follow-up because if the claim is not appropriate the coder could be liable.”

The education session, “The New Coder’s Road Map to Compliance: Fraud and Abuse in 2018,” is scheduled for 1:30 p.m. on September 22 in Ocean Drive Ballroom A-H at the Miami Beach Convention Center.