General medical billing frauds in healthcare practices

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General medical billing frauds in healthcare
practices

• Spending on healthcare in the US is intensive as
  health care spending grew 4.6 percent in
  2019, reaching 3.8 trillion or 11,582 per
  person.  As a share of the nations Gross
  Domestic Product, health spending accounted for
  17.7 percent. However, an important fraction of
  this money up to 10 of total health
  expenditure is wasted because of fraud and abuse,
  amounting to billions of dollars per year. Hence
  general medical billing frauds in healthcare
  practices are a must-know fact.
•  
• Healthcare Frauds
• Health care fraud occurs when an individual, a
  group of people, or a company knowingly
  misrepresents or misstates something about the
  type, the scope, or the nature of the medical
  treatment or service provided, in a manner that
  could result in unauthorized payments being made.
• General examples of health care fraud include
• Billing for services not rendered
• Billing for a non-covered service as a covered
  service
• Misrepresenting dates of service
• Misrepresenting provider of service

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General medical billing frauds in healthcare
practices

• Waiving of deductibles and/or co-payments
• Incorrect reporting of diagnoses or procedures
  (includes unbundling)
• Overutilization of services
• These types of healthcare frauds can be
  implemented against Medicare, Medicaid, Blue
  Cross Blue Shield, workers compensation, and
  other private entities. We will look at each
  fraud in detail in the latter part of the brief.
• Medicare Service coverage
• You should understand Medicare services to know
  frauds better. Medicare services are divided into
  Part A and Part B coverage where part A covers
  hospital care, home health care, and skilled
  nursing care while part B covers physician service
  s, laboratory tests and x-rays, outpatient
  services, and medical supplies.
• General medical billing frauds in healthcare
  practices
• Billing for services not rendered

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General medical billing frauds in healthcare
practices
It is a general and most common fraud where the
medical provider or its facility submitted claim
forms to insurance companies for services and
care that were never provided, and the
corresponding patient files had no supporting
documentation. Physicians might throw in some
extra dates and codes on the claim forms to try
to make some really easy money. In a second
scenario, gang visit, can cause fraud. When a
provider visits a nursing home and bills for
services as if they had treated most of its
residents. Alternatively, a provider may perform
a service regardless of whether each resident
needs it. Hence providers should take a closer
look while billing and bill only for services
rendered or goods provided. Billing for a
non-covered service as a covered service Billing
for services which are not covered by government
health care plans or other insurance companies,
for example, the doctor is providing a treatment,
which was considered experimental and therefore
not approved by government health care plans or
other insurance companies then doctor submitted
claim forms and still got paid for utilizing the
experimental treatment.
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General medical billing frauds in healthcare
practices
The doctor accomplished this by coding something
else that was covered by insurance plans and
policies. Hence you should look for what services
are covered under insurance plans and bill
accordingly. Misrepresenting dates of
service The provider can cause this fraud by
reporting visits and treatment of the same
patient on two separate days rather than one day
to make quick money. In this type of fraud,
claimed services are provided. But the dates are
false because its more profitable for the
providers. Misrepresenting provider of
service This kind of fraud is very dangerous
where different people impersonate a physician
and bill for treatment but lesser-educated mental
health professionals conduct the therapy in
reality. In these cases, the affected insurance
companies would still have paid for the care
provided by the lesser-educated therapists (as
long as they were licensed), but they would have
paid less. Hence you should avoid such fraud to
prevent revenue leakages.
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General medical billing frauds in healthcare
practices
Waiving of deductibles and/or co-payments Some
providers do waive patients deductibles or
copayments however most government health care
plans and insurance companies are against it and
dont allow medical providers or facilities to
waive patients deductibles or copayments as it
may lead to fraud for example- Some providers do
waive patients deductibles or copayments and
then submit other false claims to insurance
companies to make up the dollar difference by
adding a bunch of other false services to the
claim forms to increase their illegal gains
knowing that the patients are unlikely to
complain because their copayments and deductibles
were waived. Incorrect reporting of diagnoses or
procedures (includes unbundling) When providers
submit separate bills for lab services that
combine three or four tests, which are intended
to be billed as one service and in return
Medicare pays the provider more for each service
instead of a group of services. Overutilization
of services
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General medical billing frauds in healthcare
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Alcohol and drug rehabilitation facilities are
ripe for overutilization as providers use this
scheme on hypochondriac patients. Tests and exams
can go on indefinitely or at least as long as a
patient has coverage or can make payments. You
can say general medical billing frauds in
healthcare practices are the same as other
industry frauds and fraudsters are always looking
for an opportunity to take full advantage to
unjustly profit. However, every stakeholder of
the healthcare system should avoid fraudulent
behavior to avoid the further consequences. If
you want to make your medical billing clean and
avoid claim denials, then you can get with us. We
are HIPAA-compliant professionals to make your
claim submission easy and clean.