Medicare Fraud Claims, A New Challenge Even For Honest US Physicians – is Competent Billing and Coding A Way Out?


In 2010, Medicare improper payment amounted to $47.9 billion. Human and Health Services, in 2011, recovered $4.1 billion paid through reimbursements as a result of ‘fraudulent’ or ‘improper’ claims. You may be right if you think you won’t ever be among the fraudulent care practitioners who contributed to these figures because you are scrupulous.

But being scrupulous can’t prevent you from being suspected by federal authorities, thanks to the profusion of fraudulent cases – because bizarrely all some care providers have had to do to attract the scrutiny of federal authorities is over use a billing code, regardless of whether they did it for right or wrong reasons.

Why guard against Medicare fraud claims?

What federal authorities track is which codes are being used the most in terms of charges and unit volume at a national level. And then monitors the use of these codes by care practitioners. Currently E&M codes, for instance, have been found to be high in terms of charges and unit volume at a national level and are expected to be a potential target. It means merely using E&M codes can actually expose physician centers to scrutiny by Medicare authorities.

However, to negotiate this situation, you have to understand why it’s happening. And to understand this phenomenon, let us use E&M codes as an example to see how they actually can become subjects of potential abuse. (Remember, it could be any codes; E&M has just been used as an example here.) E&M services are ones provided by physicians and non-physician practitioners to assess patients and manage their care – and the code to get reimbursement is chosen based on the location where the service is performed, medical history, examination and medical decision making.

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As is evident, while some of the bases of choosing E&M codes are objective and straightforward, others are subjective in nature and dependent on availability of information (medical decision making, medical history etc) to the coder who is making the choice. This leaves a scope for human error (both deliberate and otherwise) and misjudgment.

The problems physician practices face today are in the subjective areas. Their in-house billers and coders mostly contend with ineffective in-house coordination between billing and coding and medical processes leading to inadequate medical information based on which coding judgments are made. Even if medical information is available, billers and coders are sometimes beset by lack of sound-enough familiarity with complex medical procedures where diagnoses may often overlap making it difficult to decipher where one ends and another starts leading to wrong assignment of codes and overbilling through coding of diagnoses not covered by Medicare.

With most physician centers the concern is not intended fraud but misinformation and inaccuracy in coding construed as fraud by Medicare or over coding a code under surveillance without documents and details to support it.

Guarding your practice…

You can guard yourself against eventualities stemming from this by tightening up your revenue management system so that there is adequate coordination between various processes ensuring a seamless flow of information and then conducting periodic internal audits by certified coders who will randomly pull up billing and coding documentation of recent patients to check their accuracy.

A clean in-house process or billing and coding handled by experienced billers and coders is the best way to avoid fraudulence and wrong data leading to financial penalties and resulting and attendant consequences.

MBC has helped several big and small care providers to spruce up their revenue management system through its Revenue Management Consulting services. We perform a thorough analysis of your revenue management cycle and lubricate various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training., the largest consortium of billers and coders in the US, who are experienced, certified and updated regularly, has helped medical practices improve their finances due to accurate electronic billing, intricate procedure coding, electronic filing of claims and a multi-layered application process – collectively resulting in reduced claim denials and enhanced core-business focus.

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