Q&A: When you're accused of overcoding

December 5, 2008

We have received a letter from an insurance company requesting 25 charts because the company thinks that we may have "overcoded" some patient visits. Do I need legal advice?

Q: We have received a letter from an insurance company requesting 25 charts because the company thinks that we may have "overcoded" some patient visits. The company says that we use too many 99214's (intended for visits that require at least two of the following three components: a detailed history, a detailed examination, and medical decision-making of moderate complexity) compared with our peers. Do I need legal advice?

A: The short answer is yes. Depending on the carrier and scope of the request, you may be looking at a demand for tens or even hundreds of thousands of dollars in restitution if the company concludes that you have overbilled. You may also be required to report any overbilling to your state's office of insurance fraud prosecution. Additionally, before submitting any records, you must be sure that what you are submitting is consistent with HIPAA requirements.