Medical Billing Alert – Take Measure to Avoid Charges of Fraud

Medical Billing Alert – Take Measure to Avoid Charges of Fraud

Physicians should ensure medical coding and billing practices in line with state and federal health care rules to avoid charges of fraud.

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Physicians are expected to provide quality care and bill their patients cost-effectively in accordance with services provided. Not adhering to ethical medical billing practices – whether willfully or inadvertently – will lead to charges of fraud, followed by penalties and loss of reputation.

According to the American Academy of Professional Coders (AAPC), a recent report suggests that the Centers for Medicare & Medicaid Services (CMS) are losing billions of dollars due to medical fraud. The report alleges that Medicare overbilling rose from 8.6 percent in 2011 to 12.1 percent in 2015, resulting in a loss of $40 billion annually. The report points out that if corrective action is not taken, Medicare could become bankrupt!

Stay Clear of Fraudulent Medical Billing – Practices to Avoid To avoid submission of improper claims, physicians should be well aware about what constitutes overbilling. Here are some examples of fraudulent claim submission: 

Billing for services that were not actually provided

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Billing for treatments that were not medically necessary – typically seen in nerveconduction and other diagnostic testing procedures

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Billing for low quality, worthless services

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Billing separately for services already included in a global fee, for instance, billing for an evaluation and management service the day after surgery

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Altering a patient's diagnosis to justify tests, surgeries or other procedures that are not medically necessary

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Billing each step of a procedure as if it were a separate procedure – the practice known as unbundling

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Billing for services performed by an improperly supervised or unqualified employee or by an employee excluded from participation in Federal health care programs

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Upcoding – using a higher Evaluation and Management (E/M) code than needed to get higher reimbursement

Be Prepared for Audits Determined to root out fraudulent medical billing practices, CMS is stepping up audit activity. AAPC reports that providers should be ready for aggressive post payment audit activity, along with associated recoupments from Zone Program Integrity Contractors

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(ZPICs) who are appointed to combat fraud, waste and abuse in the Medicare program.

ZPICs usually base medical necessity denials on documentation defects.

Medicare is also considering expanding the scope of its Recovery Audit Contractors (RACs) use to Risk Adjustment Data Valuation (RADV). RADV audits are proposed to be conducted to identify overpayments and underpayments associated with diagnosis data submitted to CMS by Medicare Advantage organizations.

The best way for physicians to be prepared for these checks is by -

maintaining accurate and complete medical records and documentation of the services they provide

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ensuring that claims are submitted with proper documentation

Good documentation will provide proof of care provided, support Medicare billing, and help physicians avoid malpractice charges. Proper record-keeping will also ensure that patients receive appropriate care from all the providers who are responsible for their care.

Violations of federal laws could result in nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from all Federal health care programs (including Medicare), and criminal and civil liability. CMS recommends that physician practices establish a compliance program to avoid fraudulent activities. Availing of professional medical billing and coding services can help. An established medical coding company would have certified coders who are welltrained in the guidelines that govern medical billing and coding protocols in line with state and federal healthcare laws. By ensuring accuracy in coding and billing, they can help providers enhance practice revenue and stay clear of fraud and abuse charges.

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