BusinessFinanceHealth and Fitness

Avoiding Fraudulent Billing As A New Medical Practice With Medical Coding Services

Medical Coding Services

As a healthcare professional when you are in residency likely aren’t focused on who will pay for the treatment of your patients. When you begin working, medical coding outsourcing services are important to know which players you are. The U.S. healthcare system is heavily dependent on third-party payers. As a result, your patients are often not the ones paying most of their medical costs. Third-party payers are commercial insurers as well as the Federal as well as State governments. 

If the Federal Government provides the cost of services or items provided for Medicare as well as Medicaid beneficiaries and beneficiaries, the Federal laws on fraud and abuse apply. The numerous states also have similar laws in place applicable to your supply of services under state-funded programs as well as to private-pay patients. So, you must be aware that the concerns discussed in this article could be applicable to the care of any insured patient. The issues that are discussed in this article will assist you to avoid billing fraud when you are just beginning your medical practice.

Medical Coding Services

Medical Coding Services
Avoiding Fraudulent Billing As A New Medical Practice With Medical Coding Services

Accurate Coding and Billing

Commercial and government payers trust you as a doctor to provide affordable, efficient, and top-quality medical treatment. You have a significant say in the care your patients receive. You are the one who controls the documents that describe what treatments they received and it is the basis for invoices sent to insurance companies for services that you performed. The payment by the government is typically based on the information you provide in claims documentation.

Let’s take a look at an example of the process of billing Medicare and Medicaid. Some other examples of incorrect claims are:

  • the billing of services that you did not in fact render;
  • charging for the services which were medically not required;
  • charging for services done by an unsupervised or by an unqualified employee
  • charging for services provided by an employee who was exempt from participation in Federal health insurance programs.
  • charges for services that are of such poor quality that they’re practically worthless

Defining Upcoding

Medicare reimburses many physicians for services by using Evaluation and Management (E&M) codes. Visits for new patients generally take longer than follow-up visits for existing patients so E&M codes that are geared towards new patients are able to command greater reimbursement rates over E&M codes for patients who are already established. 

Nearly 55 percent of managers stated that billing specialists are in demand 42 percent of them needed personnel to help patients follow-up. The ratio is 35.2 percent, and 34.4 percent for collection specialists and claims experts. The general trend is seeing staffing shortages at all stages within the revenue cycle. The results of the survey revealed that healthcare executives are finding hiring revenue cycle managers difficult. 

It could also be an Answer

Everyday challenges in managing your practice such as staffing shortages, as well as retaining employees can be addressed by outsourcing your medical billing processes.

Managing Staffing Shortage

Operations to manage the revenue cycle require personnel with specific expertise. If you hire an invoice, they must have previously submitted requests to the payor in the past. Each payer has its own rules for reimbursement and billing therefore the biller should know the guidelines and guidelines. Each payer has a distinct prior authorization requirement that must be taken into consideration. In the case of coding, medical specialty-specific Coders are selected. Our billers are well-trained and ensure clear claim rates with minimal claim rejection. 

The specialty-specific coders make sure the correct usage of procedure codes with the correct modifiers. At the present stage of the COVID-19 pandemic codes and billing, guidelines are continuously revised by insurance providers. Our team of coders and billers is always aware of the latest developments to ensure exact reimbursement from insurance companies.

Retaining RCM Staff

The process of retaining RCM staff is a further problem faced by practice owners. With more prestigious healthcare companies with better pay rates and more skilled employees, keeping RCM employees is a major issue. The practices are spending a significant amount of money on training. When staff who are well-trained leave the company, it can impact day-to-day RCM tasks. 

A typical example of upcoding can occur where you offer an office visit for a follow-up or follow-up consultation inpatient, however, you bill with an upper-level E&M code, as if you were providing a complete office visit for a new patient or an initial consultation inpatient. Another instance of upcoding in connection with E&M codes is an infringement using Modifier 25. 

Modifier 25 permits additional payments for an additional E&M service that was rendered on the same day, as an example of a procedure. It is possible to upcode a service if the service provider employs Modifier 25 to request the payment to cover an E&M service even if the service was not considered to be significant or identifiable as a separate entity or a step above and beyond the usual care related to the procedure.

Examples of Fraudulent Billing

The psychiatrist was fined $400k and exempted from participation in Federal health insurance programs due to not claiming that he offered therapy sessions that required 30 – or 60-minutes of face-to-face contact with the patient. However, the doctor had only provided medical checks lasting no more than 15 minutes.

Medcare Medical Billing Services (MSO) is a renowned medical billing firm that provides full revenue cycle services. We have shared important details in the Department of Health & Human Services Office of Inspector General (OIG) document on educator training for providers. The original OIG document to get a thorough understanding. 

Since you are just beginning your business, you may like to concentrate more on the treatment of patients rather than administration tasks related to medical billing. We can handle all medical billing processes for your practice, while also avoiding fraud in billing. Our billing services are secure, affordable, efficient, and tailored to the medical field you practice. For more information regarding our services for medical billing, call us by email at (+1 800 640 6409).

Leave a Reply

Your email address will not be published. Required fields are marked *

Back to top button