Different Types of Medical Billing Fraud and Abuse

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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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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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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