Obviously, to receive proper reimbursement it is very important to have accurate coding practices for all health care practitioners however; here are several reasons. A group that is often involved in the billing process is nurse practitioners. Generally they are billing for their own services or they may be using a billing form (superbill) provided by their employer by marking procedural codes and diagnostic codes in order to bill for their services. The responsibility for the accuracy of the coding and billing, as well as for maintaining medical records that support the diagnosis code and procedural code that is being used to bill for specific services, is the professional provider or the nurse practitioner.
Keeping up to date with accurate coding procedures is very important when billing to receive maximum reimbursement. However, due to new codes being added, modified or deleted, this may cause an impact on reimbursement. Sometimes the definition of a code may not be so clear. That’s why it is vital to utilize sources that are available to the medical community. Such as workshops, online information and online telephone consultation services for health care providers to get better clarification on a code before billing.
It’s also important to remember that even if billing by the physician or nurse practitioner is outsourced to an outside billing service or a trained billing clerk that is onsite, it is the person on whose professional licensure the care and billing are based is the person that is responsible for accurate billing. A nurse practitioner or a physician still has to learn something about reimbursement and coding.
Any health care professional who knowingly cheats on coding to enhance their reimbursement, can be guilty of both civil wrongs which is considered a “breach” of the insurance contract, and it’s considered a crime, which can lead to costly legal fees. Billing fraud can also result in having to return part or all of the wrongly paid money, fines, loss of their professional license and possibly serving time in prison.
How do fraudulent claims get noticed? There are several ways. Some insurance carriers have fraud detection software which they use to analyze data. When unusual billing patterns are discovered, they initiate an investigation. Sometimes it is the patient that is complaining about the amount of the bill or services that were billed. Employees have revealed on their good conscience of fraudulent practices and don’t want to be part of the scheme or it violates their own ethics. Bottom line is physicians or other health care providers who engage in this type of behavior have been costly and have led to them no longer being able to practice in the medical field.