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Billing Integrity Program Complaint

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Billing Integrity Program Complaint

The Billing Integrity Program uses information from the public to assist in the prevention and detection of inappropriate medical billing practices

Please include as much detail as possible to allow the Billing Integrity Program to investigate. You do not have to include your name if you wish to remain anonymous. Please note, the program cannot disclose the outcome of any investigation due to the need for adherence to the Medicare Protection Act and the Freedom of Information and Protection of Privacy Act.

If you would like more information regarding the monitoring and audit of billing patterns of practitioners please contact the Billing Integrity Program at 1 877 278-0835.

Complainant Information

Do you wish to submit this complaint anonymously?YesNoMissing or incorrect value

Details of Complaint

Date/Date Range of IncidentMissing or incorrect valueInclude month(s), day(s) and year(s) that the incident occurred

Complaint TypeInappropriate BillingPrivate Charges / Extra BillingQuality of CareOtherMissing or incorrect value

Practitioner(s) InvolvedMissing or incorrect value

Patient(s) Involved

LocationClinicHospitalMissing or incorrect value

AddressMissing or incorrect value

Summary of ComplaintMissing or incorrect valuePlease give a detailed description of what took place, and when. Please include relevant dates, names, addresses, the misconduct that occurred, and any additional information you feel is pertinent.

Please attach any relevant documents

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HLTH 8125 2024/03/25

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