Billers and Coders in Demand As They Help Physicians Evade Health Care Fraud!

With increasing healthcare fraud and healthcare costs, physicians are working hard to prevent this development. Most physicians feel safe utilizing some cautionary steps, especially as the feds definition of “fraud”

may encompass much more than what a physician may consider as “fraud”. This has led to a marked increase in demand for proficient medical billers and coders by physicians.

Industry standards


  • In 2003- $85 bn. was used up by  health care fraud, from the $1.7 tn. spent on health care
  • In 2004 - Approx. 14% of Medicare and Medicaid health care costs were spent fraudulently
  • In 2007 -False Claims Act recoveries equaled nearly $1 bn.
  • In 2007 - Department of Justice opened 750+ new investigations of health care fraud, while the Federal Bureau of Investigation investigated almost 2,500 health care fraud cases

In 2011 - HHS recovered $ 4.1 bn. in health care fraud

In 2012 - The government allocated an additional $350 mn. for anti fraud policing

Health care fraud is the most apparent and worrying factor that has increased health care costs!

Health Care Fraud and the Fed

With government programs like Medicare and Medicaid responsible for financing a significant portion of funding in the health care field, they are often targeted for fraudulent behavior. However not just impacting government programs such as Medicaid and Medicare; health care fraud is a massive problem today leading to an increase in health care costs and affecting the entire health care system.

Why Health Care is susceptible to Fraud?

  • Complexity Increase in technology, vague methods of payments and policies has led to the health care industry to be vulnerable to health care fraud
  • Increased ambiguity Reimbursement rules and methods are constantly changing leading to confusion
  • Partial knowledge - Fraud control started in the US only 15 or so years earlier, with experts only partially informed about the best technique to follow. Also there are very few generally accepted fraud audit field standards available
  • Limited Medical Knowledge- Investigators with inadequate medical knowledge may find themselves at a disadvantage while challenging respected health care professionals

How can medical billers and coders help control health care fraud?

Medical Billers and Coders in-depth and specialized knowledge can help reduce complexity, ambiguity and also help improve communication between payers and providers. Additional areas where coder’s involvement may help -

  • Training- coders expertise can help train providers on accurate method of coding, reading guidelines and following regulations
  • Consultation - with their specialized knowledge they consult practice owners on areas requiring up gradation like - an office administrator trained in coding, improved payment systems and reimbursement guidelines
  • Examine coding patterns - of the practice along with comparing them to different standards like the national utilization data collected by Medicare, which can help in recovery efforts
  • Accurate Coding and Billing- this increases payer trust in the physicians, helping in timely reimbursements
  • Right documentation- this serves as the basis for bills sent to insurers for services provided by the provider, accurate bills can help evade large number of health care frauds.
  • Coding and documentation audits on a regular basis -which is critical to know whether the CPT coding, ICD coding and documentation support each other. Certified coders can review few charts randomly chosen and provide a detailed report on coding, billing, and documentation

Medicare billing won't consider anything which isn't documented; hence physicians documentation is a high priority with physicians. It also helps address challenges raised against the integrity of physician bills; hence here too the need of medical billers and coders for physicians is further amplified.

Help prevent health care fraud with MBC believes that when it comes to finding the weak spots in the billing system where errors are most likely to occur and monitoring it, hence the coder’s scrutiny of payment records and claims processes can go a long way in controlling health care frauds while certifications can help bridge this gap. Most of MBC’s billers and coders are certified in CPC, CCS, CPAT, all of which requires the ability of billers and coders to accurately apply CPT and HCPCS procedures and supply ICD-CM diagnosis codes.

Another effective way of evading frauds is by efficiently using new technology and constantly updating oneself with the new regulations and compliance programs. MBC job portal and regular billing & coding newsletters provide a vast pool of opportunities and knowledge to our countrywide network of highly experienced billers and coders. With the regular updates on the current regulations and compliance changes in the industry MBC experts tend to follow all regulations governing the federally funded health care programs.

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