Medical billing experts estimate that the US Government loses 30 cents of every dollar earned from fraudulent practices and medical billing scams. With confusing Medicare regulations spanning over 45,000 pages, an endless supply of loopholes and technicalities susceptible to illegal utilization, and the average person’s inability to wade through a mountain of paperwork and medical jargon, it’s no wonder that people and the government alike lose thousands each year to medical billing fraud. Here are five of the most common types of medical billing fraud and how to avoid them.
A patient enters the hospital to undergo treatment for a sprained ankle, but the bill submitted by the hospital to the insurance company is for a broken ankle. How does this happen?
This fraudulent practice has been coined as “upcoding,” since your doctor or healthcare provider must attach a CPT (current procedural terminology) code to each procedure performed — and that code dictates how large or small the subsequent bill will be. Since its often large insurance companies who are processing thousands of computerized bills on a regular basis, many improperly coded procedures are easily overlooked.
In September 2011, The University of Texas Southwestern Medical Center at Dallas paid a $1.4 million settlement to resolve allegations of upcoding of Medicare and Medicaid claims. It was a whistleblower who brought attention to the fraudulent practices and created the lawsuit in 2007, and the care center never admitted wrongdoing — but had to pay the price for what was debatably a mistake.
“One of the most common types of Billing fraud has to do with services being billed that were not actually performed. This type of fraud impacts the cost of health care because it drives up the cost by the mere fact that the charges are not justified but there are also millions of dollars spent each year tracking and finding this fraud and stopping it from happening. The Government in the past 3 years has put in place RAC’s (Revenue Audit Contractors) who are paid a % of any fraudulent or incorrect billing practices,” said David Doyle, CEO of CRTMedical.com.
In January 2012, a Maryland orthopedic practice agreed to pay $2.5 to the federal government in a settlement over allegations that they had fabricated hundreds of false bills for visits that never took place, and doubled-charged for X-rays in order to receive higher reimbursements.
Not only does this type of fraud take a massive financial toll on the government, but it can affect a patient’s health insurance as well. Fraudulent claims for procedures that never happened still show up on the patient’s medical report and can therefore affect their insurance or the way future doctors treat them.
Inflated Hospital Bills
Linda Burdick recently felt the sting of inappropriately inflated medical bills when she received a hospital bill for $60,00 after enduring a back surgery that was supposed to be covered by insurance. After hiring two billing investigators who demanded itemized accounting, Burdick discovered gross overcharges for things like six surgical screws — which cost $1,750 each.
Health care navigator Liz Osborn said “I’ve never seen a hospital bill that I thought followed all the regulations correctly. Not once.”
The hospital was barely able to defend itself, meekly claiming that there was “no evidence of overcharges in her bill” but that they would be “willing to correct any mistakes.”
It’s important for all patients to rigorously review all of their medical bills for mistakes, overcharges, and double-charges. All patients have the right to an itemized bill and can request one from the hospital where they were seen.
Unbundling happens when multiple procedures meant to be billed in a package deal are billed separately, therefore creating a higher invoice.
Unbundling is another form of upcoding, also called “fragmentation.” This usually affects patients who have Medicare and Medicaid, since both typically offer special reimbursement rates for specific groups of procedures commonly performed together, such as blood test panels that need to be sent out to the lab. Health care providers attempting to fraudulently increase profits may remove the the special package rates and bill each component of the testing separately.
Geneseee Valley Cardiothoracic Group recently shelled out $2 million to the federal government to settle a lawsuit which alleged that submitted claims for “assistant attending surgeons” during surgery were false. Because qualified cardiothoracic residents were present during those times, assistant attending surgeons did not accrue a fee under Medicare’s regulations. If it hadn’t been for whistleblowers calling attention to the issue, this highly specific type of fraud may have gone unnoticed.
Self-referral happens when a physician ordering tests on a patient refers himself or a fellow faculty member from whom he receives financial compensation in return to do the testing. For example, a surgeon who suggests and encourages a surgery that he or she would perform himself is illegal. The law prohibiting self-referral does so in an attempt to prevent the promotion of unnecessary procedure and overutilization of services.
Unlawful profits are earned from self-referrals because medical bills can be driven up due to the conflict of interest involved, and the Stark Law prohibits this type of methodology.
Great article, I didn’t know most of these…but how do you avoid them???
I am no longer in practice, and am well aware of these 5 technics. I retired early because it was so difficult to earn a living honestly. The reimbursement rates are so low that it forces some doctors and hospitals to do some or all of these ways to make money. Most of the fees paid for a service are really a joke. Ask your congressmen to accept a salary of 60% less than they have now, then pay them 80% of that and tell them they have to get the rest of the 20% from another source or good luck. Solution, raise the reinbursement rates to a reasonable level, and this would cease.
Very interesting. I just recently had an interesting experience related to what you are saying. I got a letter from dshs that they have approved me for a capsule endoscopy (91110) not to exceed $582.11. The doctors assistant said he could not do it for so little. That that barely covered the cost of the video camera let alone for the physician interpretation and report. I looked up online to find out what people are getting billed for that procedure. The average was between 2k to 3k. It kind of made sense to me that he should truly get more. After all, its not just any camera. Its practically a miniature camera/computer as it hast to transmit to a belt I wear.
Medicare pays 40 cents on the dollar, and those same “confusing Medicare regulations spanning over 45,000 pages” make compliance impossible. So my question is: why bother treating Medicare patients anymore? People like you complain incessantly about fraud, whistleblowers target your practice to find any mistakes you might make, and now there’s a shortage of MDs to take elderly patients>
I dont think a emergency room visit of 30 minutes a blood pressure test and a blood test should cost $5,600+ call me FN crazy? Delray Beach,FL Medical Center on 12/22/2013
How about being billed for the delivery of my baby from a hospital i didnt chose…before i even have her
Assuring me they are in-network, collecting co-pay, then 3.5 months later trying to bill for the full cost of the visit… also, $15,000+ for a 20-minute colonoscopy… really??? Then turning around and billing me for additional $5000 that the insurance didn’t pay for…really????? It’s absolutely disgusting the unfair business practices that go on in the medical field. Funny, any other industry would be charged with RICO… maybe rather than funny this is ironic given the enormous cock-up that is ObamaF-eredCare and everything it claims to do and really doesn’t.
Knee arthroscopy the dr billed me over 25k for him n another k for his physicians assistant I called the billing department m was today not to worry dr is put of network n should get paid “good” I would only be responsible for the in network deductible “cause we don’t balance bill!
Have 2 issues. Do doctors get reimbursed higher allowed amounts if a surgery is billed as outpatient facility, than they would if the same procedure was billed as surgery in an office setting? My GYN did a hysteroscopy in her office ( where my exams are BILLED as place of service :Office), but was billed as outpatient facility surgery. So, instead of the copay I was expecting to have to ay, I am liable for paying the entire allowed amount because facility surgery is subject to my deductible. I really would love an answer to this. My second issue is who do I file formal complaint with over a provider that has 3 times now billed for reading of inpatient radiological services. All 3 of those services were done outpatient. Fought for 5 months on the first one finally they agreed to mail a paper claim in, and billed it outpatient. They said it was their billing software that was at fault, and was incorrectly coding. Ok. Fine. But, 2 months later, different procedure, same radiologist for reading and SAME thing. Billed as inpatient. That time it only took 2 months for them to finally bill it on paper and again say, oh, we’re sorry, it’s our system. Somehow I missed an dob for the third time, and don’t remember getting bill. f I did, I thought it was a bill from the second instance. Got collections letter. I am OVER this. They have been made aware of this happening, have admitted their system is not coding correctly and they continue doing this. Do they get paid more in the end if it is billed as inpatient? Here again…outpatient would cost me @
$0, but, inpatient is subject to deductible. I want to know who to report these people to as it is obvious to me that they are not going to fix the issue.And just because I pay attention to my insurance benefits, I have to wonder how many other people have had to pay their deductibles to these people when, in fact it should not have cost them as much?
Would billing for inpatient services when the service was performed outpatient be considered “upcoding”? Also, surgical procedure in my doctor’s office which bills as place of service office for exams, was billed as place of service outpatient facility. Is that legal? Completely changes my insurance coverage and what I owe in BOTH instances. And if either of those scenarios would be considered upcoding, who/where would I report those providers to?