In the case of medical fraud and abuse ignorance is not bliss. Your "honest mistake" could lead to a situation that put you the health care provider or you the medical biller at risk for investigation of fraud, waste, or abuse if it continues and is not checked.
Since a simple mistake can be considered fraud; I thought it would be timely to discuss in this week's newsletter as a reminder what is considered by the Office of Inspector General to be fraud and/or abuse and to briefly state the differences.
First of all, fraud can occur when deception is used in a claims submission to obtain payment from the payer. A person who knowingly submits a false claim to benefit themselves or others commits fraud. Fraud can also be interpreted from mistakes that result in excessive reimbursement. Unfortunately, no proof of "specific intent to defraud" is required for fraud to be considered.
Second, abuse means incidents or practices by physicians, not usually considered fraudulent, but are inconsistent with accepted sound medical business or fiscal practices.
Examples of Fraud:
- Forgiving the deductible or copayment
- Altering fees on a claim form to obtain higher payment
- Upcoding (e.g. submitting a code for a complex fracture when the patient had a simple fracture)
- Billing for services not provided (phantom billing or invoice ghosting) or for an office visit if a patient fails to keep an appointment and is not notified ahead of time that this is the office policy
- Shorten (e.g. providing less medication that what was billed for)
Examples of Abuse:
- Failure to make required refunds when services are not reasonable and necessary
- Calling patients back for repeated and unnecessary follow-up visits
- Referring excessively to other providers for unnecessary services
- Charging excessively for services or supplies
- Breaching your assignment agreement
Health care providers must be aware of the potential liabilities when submitting claims for payment that are deemed to be "fraudulent" or inappropriate by the government. The government may impose significant financial and administrative penalties when health
care claims are not appropriately submitted, including criminal prosecution against the offending party. Fraud, according to the Office of Inspector General, can result from deliberate unethical behavior or simply from mistakes and miscues that cause excessive reimbursement.
Be sure that your Medical Biller has learned every part of the coding system that is related to procedures, services and medical products for your practice. Physician offices should be interested in finding Medical Billers who are concerned with getting their job right.
Many law suits are founded upon billing errors rather than intentional fraud. This highlights the point and necessity of hiring and keeping on staff those who are well qualified in medical billing services that can help the practice to avoid the potential of being found fraudulent.
In today's economy you need to cut expenses and increase revenue. Don't risk the chance of having an inexperienced biller process your claims. The risk is too high!
Source by Marina Hall
