In part II of this article we will further discuss costly medical billing practices. In some cases, these have led to the loss of medical licenses for false reports include billing unnecessary services, double billing, upcoding or altering CPT codes, unbundling and false diagnoses.
Unbundling is when you charge separately for a visit or a procedure that is normally part of another procedure or visit. Double billing is when you bill for the same procedure multiple times on different dates.
Upcoding refers to using a higher procedural code than what was performed.This includes billing for services that the patient did not receive or using codes that are at a higher level of what really took place during the visit or procedure. Some examples of that are where a practice submitted bills for office visits for established patients on days where the office was closed, where the physician was not in the office or on vacation and on holidays and weekends when the office is closed.
Another example is when a physician billed for office visits for parents and siblings when one child was brought into the office for a visit. The parent had never been seen before but the physician used all the information provided for the insurance where the parent was the subscriber of the health plan, so it was easy to gain access to bill under the parent as well as the child.
Some health care providers advertise “free” services. When the patient arrives it appears to be a “free” service but ends up being charged for the office visit and other procedural codes.
Other costly practices include failure to produce or complete medical records, which are required to back up billing codes, delegating treatment to individuals that are not qualified or it is not in their scope of practice, and performing procedures and tests that are not with valid consent from the patient.
Billing fraud leads to higher premium assessments by the insurance companies. HIPAA prohibits billing for medical services “that a person knows or should know are not medically necessary.” Also violating HIPAA laws and guidelines can result in monetary penalties up to $10,000 and an additional cost of 3 times the dollar amount for each claim. These crimes are also punishable by up to 10 years in prison or even life in prison if a patient dies as a result of fraudulent activity.
Billing fraud is costly for all those involved, the practice, the doctor and their license and more importantly the patient. Fortunately, most health care providers are honest and dedicated to helping and providing the best care for their patients and only want what’s best for them and their medical practice.