Medical billing fraud costs the federal government and private insurance companies billions of dollars every year. Some of this is unintended due to billing errors or fraudulent medical billing and coding services’ poor business practices. On the other hand, medical fraud can be deliberate and result in criminal charges. Because fraud often takes a long time to detect, healthcare providers are often hit with charges once caught.
Due to the current medical reimbursement system in the United States, fighting fraud and abuse in medical claims is a difficult task. Although most providers submit truthful and accurate claims, a small percentage of fraud capitulates to the financial incentive to inflate the complexity and quantity of billed services. Without extra effort, these inaccuracies are rarely detected. Patients are poor auditors of their care because they are largely unaware of actual costs and the consequences of unethical practices.
While the traditional “pay and chase” method of pursuing funds recovery is effective in cases of fraud, it is less effective in cases of overbilling. Why? Because it’s challenging to tell the difference between actual fraud and normal variation.
What to Look for in Healthcare Fraud?
There are many types of healthcare fraud, but the most common and costly is fraudulent medical billing and coding service provider fraud. Doctors, nurses, equipment providers, pharmacists, and others order or provide healthcare services, supplies, or treatments. That’s right, the physicians we entrust with our lives are frequently the perpetrators of these crimes. Anyone can fall victim to healthcare fraud, so you should read and follow the tips provided later in this article. Untrustworthy service providers defraud customers in several ways. Some of the most common illegal activities are as follows:
- Billing in excess
- Up coding
- falsifying documents
- Extravagant services
Forwarding too many bills is one of the easiest types of medical fraud for an insurer to detect. Insurers typically have accurate information on a healthcare facility’s size and services. They also have demographic information on the area, which tells insurers how many and what types of procedures a medical practice can expect to perform over time. An insurer may not be alarmed by a short-term increase in a procedure, but a long-term increase that lasts months or longer may warrant an audit.
Physician groups can detect excessive billing because they know how long it takes medical billing and coding services to diagnose and treat patients for a specific condition. These organizations can use this data to estimate how many patients a practice can see in a day. A solo practice that submits 100 insurance claims per day, for example, is almost certainly committing fraud. The most common method of detecting fraud is the physical impossibility of seeing as many patients as the number of claims submitted.
Upcoding is assigning a diagnostic code for a more severe condition than the patient has identified. This practice increases revenue because insurers pay more for severe conditions. A practice that submits more claims with these codes than expected may be subjected to a full audit by the Office of Inspector General (OIG).
The Office of Inspector General also examines all of a practice’s inpatient codes to see if any conditions are unusually severe. If the OIG finds that practice is purposefully overcoming claims, it may be subject to harsh penalties.
Improper Medical Documentation
Falsified records are one of the most challenging types of medical fraud to detect because many of these cases are unintentional. One of the most important causes of this problem is that many types of claims can be submitted without medical records. This option enables healthcare providers to thoroughly understand insurer policies to increase reimbursements without triggering an audit by manipulating claims. However, altering medical records to increase the claim amount is illegal. It’s also against the law to purposefully omit critical information from a claim, which is frequently done to hide treatment errors. It is also against the law for a medical coder to change a claim’s code to increase reimbursement.
Excessive Patient Care
Another common form of medical fraud is billing the insurance company for services that the patient does not require. This practice includes billing for services that were never rendered and providing unnecessary services. Intentional charging for excessive services can be challenging to detect because it often occurs unintentionally due to poor medical billing and coding services. Healthcare facilities should have processes that effectively capture the charge for each service, though this isn’t always the case.
How can you Protect Yourself from Medical Billing and Coding Fraud and Abuse?
Find out about the Healthcare Laws and Regulations
You must be familiar with healthcare regulations, whether you prefer in-house or outsourcing medical billing and coding services. You know everything there is to know about the False Claims Act (FCA). This prevents healthcare providers from submitting medical claims for services that are either too inexpensive or too costly. Medical professionals should also be aware that they may lose compensation in the future from federal insurance agencies, Medicare, and Medicaid. The federal government can fine offenders up to three times their disbursements for each false claim. As a result, to prevent medical fraud, healthcare providers ensure compliance with all federal regulations and laws.
Ensure Proper Coding
Unbundling, up coding, and over-coding are the most common coding errors that lead to fraud and medical abuse. As a result, you should hire certified and experienced medical billing and coding services to help you because your coding staff is in charge of translating your patients’ diagnoses and medical treatments into standard codes. On the other hand, medical coders are highly trained to ensure accurate coding while adhering to CMS and NCCI guidelines. However, if you cannot manage the coding and billing process on your own, these tasks should be outsourced. Non-compliance and fraud detection is taught to offshore billers and coders. They are skilled at spotting ambiguous or suspicious paperwork that could lead to fraud. Furthermore, they maintain accurate billing practices to avoid overcharges and other forms of fraud.
Additionally, because medical billing and coding services are always changing, keeping your teams trained is critical. This will keep them informed about the most recent and specific codes to use. It will also reduce your rejection rate.
Maintain Accurate Medical Records
It’s possible that the issue started with front-desk information. Billing errors are more likely if your registration staff does not carefully capture patients’ demographic information. It is also necessary to document information in medical records daily. As a result, healthcare organizations train front-line employees to keep accurate medical records. Medical professionals can also use this to defend themselves against medical billing and coding fraud.
You should also stop using manual data processing methods to improve the efficiency of the patient’s records. Errors are reduced when electronic health records (EHR) are used.
The electronic exchange of health information can help you keep your billing and coding processes accurate.
Choose Bellmedex, your Dependable Medical Billing and Coding Services
The best way to ensure correct codes and no up coding is to entrust your daily coding to a medical coding company. Bellmedex Health Solutions assists providers in improving coding accuracy and identifies inefficient practices or other areas of concern. To avoid upcoding everyone has a responsibility to report accurate information based on patient documentation and the associated costs. We discuss closely with our clients to help them become more proactive in their coding practices and earn an actual return on investment.
Compliance with Bellmedex Medical Billing and Coding Services
When you use Bellmedex’s professional medical billing services, you can rest assured that your coding is ethical, accurate, and compliant with all regulatory requirements. Such businesses employ properly trained coders who continue their education to stay current with changing rules and regulations. All claims are submitted after a thorough review for accuracy. All potential risks are examined to ensure error-free processes, and appropriate safeguards and compliance controls are implemented.