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Fraudulent Medical Billing – An Overview Fraudulent medical billing is one
of
the major contributing factors to
the
rising healthcare costs in the U.S.
This
can be attributed to human or computer
error,
but
in
some
cases it may be an intentional deception by the hospital, doctor, insurer or other medical billing specialist. A person who knowingly submits a false claim to benefit himself or others commits fraud. Fraud can also result from medical coding and billing errors that reimbursement.
Examples
lead of
to fraud
excessive may
include
submitting claims for services not provided, falsifying claims or medical records and misrepresenting dates, frequency, duration or description of services rendered.
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With today’s incredibly complex medical billing system, medical providers and organizations are bound to make occasional mistakes when coding the services provided to patients. Most Common Types of Medical Billing Frauds and Abuse That Affect the U.S. Healthcare System
•
Upcoding: Submitting a claim for a service more comprehensive
than
the actual service
provided
leads to upcoding. For instance, billing for a broken ankle while the actual treatment provided was for a sprained ankle. •
Cloning: This is the fraud practice of using an EHR system to automatically generate a more detailed patient observation profile by copying the details of another patient with similar symptoms to create the impression that a more thorough examination was done. The OIG (Office of the Inspector General) has indicated that this practice leads to improper
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payments, incorrect documentation of records, and considerable risk to patients. •
Phantom billing: One of the most common types of billing fraud has to do with services being billed that were not actually performed. This also affects healthcare costs in the millions of dollars invested in tracking and prevention.
•
Inflated hospital bills: Inflated medical bills occur when patients are billed more than a procedure should have cost, for extra equipment not actually used, or for the same service twice. Deliberate billing mistakes also contribute to inflated hospital bills. Patients can use an itemized bill to detect these fraudulent billing practices.
•
Service unbundling: With this practice, bills are provided for multiple procedures separately rather than billing them together as a bundle, with the aim to increase profit.
•
Self-referrals: This is when healthcare providers refer themselves or a partner provider to perform a service, usually for a financial incentive.
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Double billing: This is the practice of charging more than once for the same service that is similar to billing using an individual code and then again as part of an automated or bundled set of tests.
EHR Technology Can Contribute to Healthcare Fraud According to a recent report from the OIG for the Health and
Human
Services
Department
(HSS),
flaws
in
electronic health record systems (EHR) can also lead to overcharging. The online survey for this report found that
CMS
had
provided
only
limited
guidance
to
Medicare contractors on EHR fraud vulnerabilities. HSS officials have issued severe warnings against healthcare professionals
who
use
web-based
medical
billing
systems to overbill. Real Life Cases of Medical Billing Fraud 1.
Report from the official website of the United States Attorney’s Office - Engage Medical, the medical billing group and three other medical practices have
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agreed to pay a total of $3,340,979 to resolve claims that Engage Medical overbilled for nuclear stress tests conducted between July 2007 and March 2011. It is claimed that physicians and practices hired Engage to help process billings, and the company routinely billed Medicare twice for the same tests. 2.
LONGISLAND.com reports the case of a New York doctor arrested for submitting millions of dollars in false billings to Medicare. From January 2011 through mid-December 2013, Medicare was billed at least $85 million for surgical procedures purportedly performed by the doctor.
CMS’ RAC Audits To reclaim the money wasted and lost, CMS implements recovery
audits
or
RAC,
to
motivate
healthcare
providers to help create and sustain more accountable, evidence based, and streamlined healthcare services. The primary focus of RAC auditors or recovery firms is to identify overpayment of medical bills. Individual providers,
hospitals,
clinical
laboratories,
durable
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medical equipment suppliers, hospices and home health agencies
have
all
been
the
subject
of
fraud
investigations. Medical Billing Advocates of America (MBAA) has also issued a free report on the web to educate the general public on medical bill overcharges and fraudulent billing practices. Fraudulent medical billing must be avoided at all costs. This is an area that needs special attention, which may not be possible in a busy physician office setting. A professional medical billing and coding company can be of immense support here, providing the service of experienced medical billing specialists and coders who can help healthcare providers avoid billing errors and adhere to industry guidelines.