Here, in this update we shall touch upon the most important issue that has been plaguing our healthcare industry: healthcare fraud and abuse of health insurance benefits. We shall also discuss:

• How ICD-10 can minimize the quantum of healthcare fraud, and
• How crucial the billers and coders’ role will be in ensuring honest medical billing practices

Here, in this update we shall touch upon the most important issue that has been plaguing our healthcare industry: healthcare fraud and abuse of health insurance benefits. We shall also discuss:

• How ICD-10 can minimize the quantum of healthcare fraud, and
• How crucial the billers and coders’ role will be in ensuring honest medical billing practices

“Can healthcare fraud be reduced through ICD-10?”

We all are aware of healthcare fraud: it is willful exaggeration of clinical or medical billing for redeeming medical bills in excess of what providers are entitled. And there are various means to healthcare fraud:

• Billing for services not performed
• Duplicate billing for single service
• Falsified diagnosis
• Billing for a covered service when a non-covered service is performed
• Billing for a more expensive service than what is performed
• Waiving co-pays or deductibles and overcharging insurance plans

Irrespective the means, the motive has always been monetary gains. But this unscrupulous motive has grown to be so menacing that it is threatening the very institution on which health insurance operates. More than the erosion of trust between the healthcare providers and the insurance providers, it is the quantum of money lost to healthcare fraud and abuse that one needs to be worried about, on a rough estimate nearly 6% of U.S. GDP is eroded through Medicare and other health insurance related fraud.

Although the Federal Government has pledged to spend $2 billion to curb healthcare fraud, and cut $1.9 billion in Medicare fraud, we are far away from realizing the results yet. Amidst such testing times, ICD-10, it is believed, will bring in a renewed hope of preventing healthcare fraud.

Well, that also brings us to the question: will ICD-10 automatically reduce healthcare fraud?

ICD-10, just like its predecessor, is another coding system but with a difference:

1. The fundamental difference is that it is more detailed, exhaustive and all pervasive. ICD-10’s improved precision in documentation of clinical care will greatly improve the likelihood of submitting accurate claims the first time around and receiving appropriate reimbursement.
2. Furthermore, the increased granularity of ICD-10 code will help reduce the number of claims being investigated or rejected due to insufficient information. ICD-10 will solve the problems caused due to lack of detailed information contained in the diagnosis and procedure code assignment.
3. While all these positives will ensure that healthcare providers realize their medical claims fully, it also binds them to honest medical billing practices. As healthcare providers realize that chances of misrepresenting claims are getting minimized, they would invariably shun away from unholy healthcare fraud.

But, as billers and coders hold the key to realize such ICD-10 mediated anti-fraud reform, your role as medical billers and coders would eventually come to the fore in aiding your physicians to:

• Adapt to ICD-10 billing and coding practices
• Set up technology interface that complies by ICD-10 standards
• Adopt EHR practices that best conforms to HIPAA 5010, which is the foundation for ICD-10 environment

While you undertake a transformational role of educating your physicians on the efficacy of anti-fraudulent billing and coding practices, you can also count on our unique training program on ICD-10 transition – interspersed with webinars, forums, and online learning materials – for enriching your ICD-10 billing and coding knowledge.

Watch out for our next update: Most likely errors you may encounter during ICD-10 implementation