Is this considered fraud?

[Msladyajw]

I recently took on the task of helping my new boss clear some claims that were denied because of wrong credentials,
Upon reviewing some of the claims I noticed the billing code being used is what is used if you performed a covid test, But it should be for giving a covid vaccine. Could this be considered fraud? The billing is usually done by a company and I do not think she knows this is being done, But I do not know for sure, If this is not fraud I have no need to mention it but if it is or isn't I have no clue. The company I work for is not a DR or clinic. They do vaccination events, They have a NPI but they never did billing for anything until the COVID vaccine, SO I am thinking she most likely does not know, Should I mention this or just keep my mouth shut

[Michele]

I would definitely mention it to her.  You may be wrong, but if it is being done wrong it should be corrected.  If it's a clerical error, and it's corrected, it's not fraud.  But if it's being done to get a higher reimbursement then it certainly is.  But the coding for the vaccine is very different than the coding for the testing.  For example, the dx for the vaccine is Z23.  The dx for testing would be different, like either the symptoms the patient has, or exposure.  so the Z23 dx wouldn't work with a cpt for testing. 

[kristin]

Agree with Michele completely, definitely mention it to your boss. To me, this sounds like a case of "ignorance/error" when it came to what codes to bill, and not fraud. I am not sure how old these claims are, but it could stand to reason that whoever she was using for billing for whatever reason didn't switch from testing codes to vaccine codes, when the vaccine became available.

I have no idea if testing codes pay more than vaccine codes, but if they do, or vice versa, your boss could either owe money or be owed money from insurances, if these are paid claims.