Accounts ReceivablesClaims DenialsMedical Billing ServicesMedical CodingPractice AdministrationPractice ManagementRevenue Cycle Management (RCM)

Untrained Medical Billing Staff will Drive Fraudulent Risk

In order for healthcare facilities, hospitals and clinics to contain fraud or unintentional fraud, hiring to certified medical billing and coding services is of utmost importance.

Today millions of healthcare claims are processed every year by private insurers and governmental agencies like Medicare and Medicaid. Healthcare providers that submit incorrect or erroneous claims may face allegations of fraud. This might result in fines and loss of reputation and good industry standing.

When most people think of fraud, they see it as a deliberate act of deceit. But that’s not always the case. The vast majority of doctors are trying to make an honest living.

Get Perfect with Your Codes

There are thousands of medical codes and code combinations available today. They represent a type of visit, diagnosis, how a procedure was performed, whether more than one procedure occurred at the same time, the extent of a patient’s examination, etc.

Some examples of improper submissions include ‘upcoding’. It simply means using inappropriate medical billing codes to indicate that a more complex or lengthy procedure was performed. Then there is ‘unbundling’ of codes, which is using different codes for each step of a medical procedure even when one code assigned to cover all steps in the procedure will do.

Vital Points to Avoid Fraud at your Medical Facility

Know your Coding and Billing Staff.

If you want to be a smart medical; facility owner/in charge read some patient records from your own patient encounters with them. Get tips to understand what meets a level 3 for a new patient, what meets a level 4 for an established patient, and learn how to put in your record what would be the appropriate coding level. This topic is not covered or touched upon. Most physicians don’t get involved in this detail of coding, but one should be encouraged to learn it. It is critical to keep fraudster at bay.

Look for Credentials

There are some who are not exactly honest when it comes to clean medical coding and billing. It is mostly happens with government payers such as Medicare and Medicaid. Check if the medical billers and coders have ever been disciplined by their state’s Medical Examining Board. Glance through the National Practitioner Databank to see if any disciplinary actions were taken against them.

Ensure the Work is Billed Under your NPI

There are certain cases, where you can get more money from Medicare for billing under the physician provider number. However, you have to meet certain criteria to do that. There are a lot of clinics in United States that are inappropriately billing as if the physician really encountered the patient, when in reality he didn’t. If you are conducting specialty billing under the physician’s NPI number, make sure the encounter meets incident to criteria.

Observe the in-house staff and their knowledge about the current health care payment system

If you are sharp enough, you will know very quickly, within a month of working with the medical billing and coders’ team what kind of knowledge is prevalent. If they fail to get you clear cut answers as to why some claim were rejected, that’s a red flag. Be aware as there might be a tendency to do some cheating when it comes to billing.

Understand how the payment system in health care works

Understanding the payment system will help you to know why there possibly is a tendency to commit fraud on either end. The primary care clinicians are getting paid the least are going to feel unjustly paid and they may tend to feel cheated or over code or over bill a procedure. On the other hand certain doctors have, what experts call as ‘cash-cow procedures’. They may skew their practice to perform as many of these procedures as they can, even if not indicated, so they see patients in which they can perform the most highly billable procedures.

Remember that physician assistants also should play an active role in checking the health care policy and medical billing and coding procedures. The problem is not what we can do about the skyrocketing costs, but how can we bring it down.

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