Different Types of Medical Billing Fraud and Abuse %
Medical billing fraud and abuse arises
Physicians
mainly due to medical coding and
commit these errors which would make
billing errors which lead to improper
them a target of a fraud investigation.
reimbursements. Fraud is a deliberate
Committing such errors can lead to the
deception
suspension
that
results
in
an
should
of
be
careful
providers
not
to
from
the
even
the
unauthorized payment, while abuse is
Medicare
failing to adhere to accepted business
imposition of civil monetary penalties,
practices.
which, even if inadvertently committed,
Medical billing abuse can be
unintentional.
program
and
would negatively impact the physician’s reputation and practice.
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Fax: (877) 835-5442
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Billing and Coding Practices to Avoid
A study by the American Health Information Management Association (AHIMA) on medical fraud and abuse found that about half of the errors identified were the result of insufficient or lack of documentation by healthcare providers, and one-third of the documentation errors were associated with providers who did not respond to repeated requests from auditors to submit documentation. Here are some of the things that physicians need to be wary of:
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Fax: (877) 835-5442
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It occurs when a diagnosis or procedure is assigned a higher
Upcoding
cost or rate of reimbursement than the actual service. For example, submitting a claim for broken wrist treatment when the treatment was given for a sprained wrist.
Billing for Services Not Provided
An example is billing Medicare for appointments that the patient did not keep.
Using an EHR system to automatically create a more
Cloning
detailed patient observation profile by copying the similar file of another patient to create an impression that a more thorough examination was done.
This refers to charging for services that not have been PhantomCharging
rendered, which is usually done by copying from the records of other patients who might have undergone the same tests.
This is when the practice charges excessively for services or Inflated Hospital Debits
supplies. This also includes overcharging on equipment and length of stay.
This is a fraudulent practice in which a single service code is broken down to separate service codes, for getting more
Unbundling
payment from the insurance company. This practice can be either intentional, i.e., coding alteration for higher payment or unintentional due to misunderstanding of coding practices.
This refers to charging more than once for the same service.
Double Charging
For example, charging using an individual code and again for an automated or bundled set of tests.
This happens when providers ordering tests on a patient
Self Referrals
refer themselves or a partner provider to perform the test service in return for financial compensation.
This occurs due to the entry of incorrect codes when Keystroke Error
typing, which result in overcharging or in some cases, undercharging.
Unnecessary Treatment
In this case the physicians perform unnecessary tests in order to bill for extra payments.
Ensuring Billing and Coding Compliance
Coding and billing processes are clearly areas that require special attention, which a physician in busy office setting will find difficult to manage. Partnering with a professional medical billing and coding company can ensure ethical, accurate coding in accordance with all regulatory requirements. Such companies have coding staff that have been properly trained and receive ongoing continuing education to assure that they are aware of changed rules and regulations. All claims are submitted only after they are double-checked for accuracy. All potential risks are examined and appropriate safeguards and compliance controls are instituted to ensure error-free processes.
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Tel: 1-800-670-2809
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