What are the categories of improper payments in healthcare claims?

• A. Payment for items that have been inappropriately coded
• B. Payment for services that do not meet medical necessity
• C. All of the above
• D. Payment for services in which the documentation does not support the service that was ordered

Answer: (C)

Improper healthcare payments come from actions that don’t align with what was actually provided, why it was appropriate, or how it was billed. When a claim is paid for items that were inappropriately coded, the code used doesn’t accurately reflect the service or item delivered, which can inflate payment or misrepresent the service. When a service is billed that does not meet medical necessity, the payer determines there isn’t a clinical justification under their guidelines, so the payment would be non-covered or reduced. And when the documentation does not support the service that was ordered, there isn’t enough evidence in the chart to verify that the service was appropriate or performed as billed, which can lead to denial or adjustment.

All of these represent common pathways to improper payments, so recognizing that they collectively cover the range of issues is why this broad category is the best answer.