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Avoid Unintentional Insurance Abuse with Efficient Medical Billing

April 04, 2014



Healthcare industry has undergone rigorous transitions in the past 10 years to ensure efficient care cost and service delivery. In addition to that focus has shifted significantly towards patient interest and installing ways to safeguard it. With new ICD 10 and CPT coding changes around the corner and hospitals being encouraged to participate in Affordable care, insurance carriers are going to play a pivotal role in medical reimbursements in times to come. According to NHCAA, of the 2.3 trillion USD spent annually on healthcare, 3-10% is wasted on insurance frauds. This quantum can be as big as 200 billion USD and insurance carriers are successively strengthening their screening processes for claims to reduce this wastage. Types of insurance frauds which can attract unintentional insurance abuse for medical practitioners can be –

  • Provider fraud: Incorrect coding of billing for services which were not actually rendered. While care providers may have inadvertently selected a wrong code for the services given, repeated mis-coding can cause the insurance carriers to investigate and initiate medical audits
  • Subscriber fraud: This forms the largest category of frauds wherein subscribers may resort to fake provider receipts to avail insurance reimbursements, share their insurance card with another un-insured party or falsify documents to get uncovered benefits. The liability in such frauds is shared by both subscriber and provider
  • Other types of frauds also include pharmacy frauds, group frauds or employee frauds where falsification of information can put your medical practice at risk for unintentional insurance abuse

If a medical practice is found guilty of any of these categories of fraud, then the liable party will not only be charged financial penalty but also be subjected to federal prison time of up to 10 years. Not only that, the medical practice is also exposed to risk of closure in case of health insurance being detected in the practice. This unintentional insurance abuse can be, however, avoided with timely rectification of billing practices and installing efficient medical billing processes. Coding and billing processes that can effectively help you in avoiding insurance abuse are –

  • Pre-authorization with insurance carriers of procedure coverage and clarification of coding for the diagnosis and procedure if there is any confusion between CPT and ICD 10 codes to be used
  • Referring to clearinghouse coding error reports to identify commonly done coding errors and address them within the billing process itself. At times your billing staff will be mistakenly continuing with ICD 9 coding or selecting wrong codes for different procedures due to lack of training. Such problems can also be minimized by using EMR for coding and billing effectively
  • Billing practitioners at times inadvertently code various steps of procedures as separate procedures (unbundling). This can be detected as provider’s fraud and with efficient billing processes in place, it can be essentially avoided

Medicalbillersandcoders.com is a billing and coding service provider that specializes in providing end-to-end billing solutions. Our medical billing experts ensure that each step of diagnostic and procedural coding is screened for coding and compliance adherence. With medicalbillersandcoders.com as your billing partner, your medical practice can be well protected from unintentional insurance abuse.

 

Category : Best Billing and Coding Practices