No industry is free from fraud and manipulation! It may not be obvious, but this is a rising medical billing concern as well. A large number of people are involved in fraudulent billing in healthcare. While scammers benefit from this, honest healthcare providers have to pay the price.
Preventing such activities and stopping unethical behavior has become a necessity. It is vital for healthcare providers to avoid fraud in healthcare billing and save their revenue.
Medical billing fraud is not only moral exploitation, but it also results in ineffective processes and higher healthcare expenses. Every year there is a cumulative loss of billions of dollars. Reliable sources like the National Health Care Anti-Fraud Association (NHCAA) indicate fraudulent billing in healthcare as a serious matter that needs action.
Healthcare providers and practices must pay extra attention to such situations to stay away from consequences. There may be revenue losses, legal sentences, and reputational damage. Medical billing fraud also hampers the services to patients, increasing the risk of mishappening.
In this blog, we will go through fraud in healthcare billing and discuss how healthcare providers can safeguard their revenue. By the end, you will have a clear idea of how you can defy such challenges.
Let’s start by decoding healthcare fraud!
Defining Fraudulent Billing in Healthcare
Errors in the medical billing process done intentionally are the reason behind fraud in healthcare billing. The intention behind committing errors is to receive unentitled revenue. Anyone who is directly involved in the medical billing process can attempt to do this for personal gain.
There are various types of frauds, and they are:
Over-Coding
When the claims filed are of higher cost than the actual treatment offered to a patient, it is referred to as over-coding. This is an illegal way to receive more reimbursement.
For Example:
A patient spends only 20 minutes for a doctor's appointment, but he/she is charged for an interaction of 1–2 hours.
Double Billing
If multiple claims are submitted for a single treatment, then it turns into double billing. This means that the healthcare provider will receive twice the amount for a service.
For Example:
A patient receives complete treatment in a single visit, but he/she is charged for two visits with the impression that it took two sittings to complete it.
Unbundling
Various medical treatments require bundling of codes for accurate claim filing. However, when this is manipulated and billable codes are separated, it is called unbundling.
For Example:
A patient gets various medical tests done under a single treatment, but the provider bills the tests separately.
Phantom Billing
When a patient is charged for a service, he/she did not receive it in the first place; it is called phantom billing. Moreover, the billing procedure is done for medical services that were not received and were not even necessary.
For Example:
If a patient is charged for equipment that was never used, it is considered as phantom billing.
Other than the above-mentioned points, there are some more ways of fraudulent billing in medical billing. Such as rendering medical unnecessary treatments, changing the patient's diagnosis, or giving a false account of non-covered medical treatments.
How to Stop Fraudulent Billing in Healthcare?
In simple terms, preventing fraud and abuse in healthcare billing is about identifying the core cause and solving it from the root cause. Making sure adherence to compliance standards is also crucial.
If you want to be free from medical billing fraud, then the following points can help you:
Recognizing Frauds
As we discussed above, there are various types of fraudulent billing in healthcare. Healthcare providers avoid all of them by keeping the medical billing process as accurate as possible.
Over-coding can be prevented by ensuring the accuracy of codes. Similarly, healthcare providers and practices can avoid double billing, phantom billing, and unbundling.
One more way fraud happens is by imitating a healthcare provider and stealing vital information and using it for individual advantage.
The first step is identifying the reason behind fraud, and then it is all about correcting such actions. Another way to deal with fraud is partnering with a trustworthy medical billing company that can handle all this on behalf of healthcare providers.
Following Regulatory Compliance Standards
Following regulations is mandatory to avoid medical billing fraud. For this, healthcare providers need to be up to date and must also have accurate knowledge. This will enhance understanding of the law and how the legal framework acts in cases of fraud.
Being involved in a kind of medical billing fraud is illegal, and there is punishment for such actions. Medical billing services are well aware of legal consequences, and therefore they ensure a fraud-free medical billing process.
Healthcare providers only need to make sure that their medical billing partner follows all HIPAA compliance requirements and also meets all other regulatory requirements.
Focusing on Data Security
Patient data is the fuel for fraudulent billing in healthcare. Scammers steal and misuse sensitive patient data. They may try to abuse the data and file claims for medical services that were never rendered.
That is why keeping patient information is extremely important to prevent fraud in healthcare billing. In case of data breaches, healthcare providers must take necessary measures to save the information from unauthorized access.
Healthcare providers can implement strong controls like encryption and multifactor authentication to secure medical billing data. They can also outsource medical billing to enhance data security.
Double Checking the Medical Billing Steps
Healthcare providers must layout a double-checking method before finalizing claims and submissions. This is the best way to outline mistakes while documentation, coding, and claim filing.
Regular audits are meant to ensure an efficient and accurate medical billing process free from fraud. They also give an overview of what is happening and can detect warning signs in cases of unwarranted activities.
All in all, checking if things are alright twice is not a bigger hassle than facing legal consequences and reputational damage. Prioritizing cross-checking.
Building an Adherence Plan
Creating a plan to prevent fraudulent billing in healthcare and following it through can solve various problems. It involves carrying out all safety measures regularly. This also strengthens the internal system and avoids deceptive activities.
Outsourcing Medical Billing Services to Avoid Fraud
Making a healthcare practice anti-fraud is a task, but a medical billing company can handle it well. Medical billing services solve thousands of medical billing challenges, and this makes them experts at preventing fraud.
When it comes to medical billing fraud and abuse, healthcare providers may not know where to begin. However, this is not the case for medical billing services.
They can effortlessly impose safety measures and streamline the medical billing process. As a result, healthcare providers and practices can improve their revenue cycle management and optimize the operational flow.
Choose – Eminence RCM
Eminence RCM helps healthcare providers and practices in resolving complex situations and preventing medical billing fraud. Our proficient team takes care of all medical billing steps, reducing the chances of errors. We ensure accurate documentation, coding, and claim filing.
We comply with all necessary regulatory standards and incorporate technological tools to improve data security. If you are searching for an outsourcing partner that can help you prevent fraudulent billing in healthcare, then Eminence RCM is the answer!
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