FWA Insights: Risks and realities of providers billing outside of their specialty

Cotiviti Blog · 2 months ago · 105 views

When providers bill for services outside of their area of expertise, there’s a risk that patients may not receive the most appropriate or effective care. Many payers and regulatory agencies require providers to bill only for services within their approved specialty, while licensing ensures that providers have met the necessary education, training, and competency standards. Billing outside of one’s specialty can violate these policies, leading to penalties, audits, or even exclusion from government programs. In this edition of FWA Insights, we break down the steps special investigative units (SIUs) can take to determine if a provider has billed for illegitimate services outside of their specialty to help ensure regulatory compliance and reduce fraud, waste, and abuse (FWA).

When providers bill for services outside of their area of expertise, there’s a risk that patients may not receive the most appropriate or effective care. Many payers and regulatory agencies require providers to bill only for services within their approved specialty, while licensing ensures that providers have met the necessary education, training, and competency standards. Billing outside of one’s specialty can violate these policies, leading to penalties, audits, or even exclusion from government programs.

In this edition of FWA Insights, we break down the steps special investigative units (SIUs) can take to determine if a provider has billed for illegitimate services outside of their specialty to help ensure regulatory compliance and reduce fraud, waste, and abuse (FWA).