I’m trying to find documentation from CMS or the False Claims Act that specifically indicates that it is fraud or false reporting of claims to bill out a lower level code for reimbursement when the higher level code that actually occurred is not payable due to the fact that an authorization was not obtained. Since the lower level does not require an auth and auth wasn’t obtained for the actual level of care that was provided, I’m being asked to downcode to the level that does not require an auth. This is not just for one claim here or there, this is between 50-80% of the services provided where auths weren’t obtained for the correct level of care so the provider wants them downcoded to the level that doesn’t require an auth.

Does anyone have documentation that they could send me from CMS or from the False Claims Act that specifically mentions downcoding abuse.

Thank you for your help!