Medical Billing Fraud And How To Prevent It

Medical billing experts suggest that the government loses 30 cents of every dollar from fraudulent practices in the medical community

. While part of the reason may be that there are more than 45,000 pages of Medicare regulations, there are other factors as well. Consider this:

- Last year, Allstate insurance filed a complaint against a medical billing company in Michigan alleging insurance fraud, misrepresentation and unjust enrichment. The alleged scheme involved solicitation of persons involved in automobile accidents and sending them to clinics controlled by non-medical personnel who directed medical care. Unnecessary services and testing were allegedly ordered.

- Medicare fraud which is a felony, can be committed by providers, suppliers recruiters, companies and beneficiaries

- The government doesn't pay claims. Claims are paid by private insurance companies.

Types of Fraud

Following are some types of medical billing fraud:

- Submitting bills for services not provided

- Performing an unnecessary service

- Up coding a service- This happens when a surgical bill is submitted when in actuality a bandage was placed on a cut

- Unbundling of services- This occurs when bills are submitted for individual tests when the tests were intended to be billed as one service

- Billing non-covered services as covered services

- Soliciting offers or receiving a bribe or kickback (as in the Allstate case above)

- Allowing someone else use a Medicare card

Screening Employees

Medical billing fraud can be prevented with the implementation of employee screening:

- Make sure that when you hire a medical biller, you perform a background check,

- Only hire certified medical billing professionals. Discover where they're certified from and ask to see their certificates.

Compliance Program

Whether you have a medical billing company or a doctor's office, establish a compliance system designed to prevent fraud. This means that the system has to have some teeth in it. Assign high level personnel to oversee it and grant him or her the power to recommend consequences if fraud is detected.

Communicate the procedures, standards and the reason for the program to all employees. Include the establishment of an audit system, a method to report any abuses without fear of retribution and penalties if the standards are breeched. This includes disciplining people who perpetrate fraud.

Make the compliance process part of your company and make sure all of the employees are aware of it. It's an important part of your office procedures.

If you're a physician's office or hospital seeking to hire a medical bulling firm, ask about their compliance program when you're performing your due diligence.

by: Ronald McLaughlin

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