A PMHNP notices that insurance is being billed for 60-minute psychotherapy sessions when the PMHNP is only providing 15-20 minute medication management visits. What should the PMHNP do?
Explanation
Healthcare billing fraud is a serious legal and ethical matter. When services are billed under a provider's name and NPI number, that provider is responsible for ensuring the accuracy of those claims. Billing for 60-minute psychotherapy sessions when only 15-20 minute medication management visits are provided constitutes upcoding — a form of healthcare fraud that can result in federal prosecution under the False Claims Act, exclusion from Medicare/Medicaid, loss of licensure, and significant fines. The PMHNP must immediately bring the discrepancy to administration, ensure correction of billing practices, and may need to consult with compliance or legal counsel regarding past inaccurate claims.