ASHA-IIE-MISREPRESENTATION — ASHA Issues in Ethics: Misrepresentation of Services for Insurance Reimbursement (2018)
What does ASHA-IIE-MISREPRESENTATION say?
Misrepresentation of services for insurance reimbursement, funding, or private payment is fraud and violates the Code of Ethics. Key areas of concern: (1) Fraud — knowingly misrepresenting diagnoses, services provided, or qualifications to obtain payment. Types include: billing for services not rendered, upcoding (billing for more complex services than provided), unbundling (separating procedures normally billed together), billing for individual services when group services were provided. (2) Abuse — practices inconsistent with accepted standards that result in unnecessary costs. Includes: excessive services beyond what is clinically necessary, routine waivers of copayments, and inappropriate referral arrangements. (3) Common pressure situations: employer pressure to meet productivity targets, insurance companies denying needed services, pressure to keep clients in therapy longer than clinically warranted. (4) Ethical responses: document clinical necessity thoroughly, appeal denials through proper channels, refuse to engage in fraudulent billing regardless of employer pressure, report fraud if observed. (5) Federal and state laws (False Claims Act, Anti-Kickback Statute) carry severe penalties for healthcare fraud. Relevant Code sections: Principle I Rule Q (accurate billing); Principle III Rules D, G (no fraud, no false statements).
Official source: read the full text in the ASHA Code of Ethics (2023) (official document).