Medical Billing Fraud
What is Medical Billing Fraud? It is an attempt to fraudulently obtain payments from insurance carriers. Medicare and Medicaid are the most susceptible to fraud because of their payment arrangements. Fraud in medical billing cost tax payers and medical providers millions of dollars annually. In 1996, HIPPA established the Health Care Fraud and Abuse Control Program (HCFAC) to help combat medical billing and health care fraud. Fraud is an act done with the knowledge that you are doing wrong. Fraud is the intentional deception and misrepresentation that is to result in an unauthorized benefit. Abuse is the charging of services that are not medically necessary. False claim schemes are the most common type of health insurance fraud. The reasoning to do fraud is to obtain undeserved payments for claims. Some schemes to watch out for are: * Billing for services, procedures and/or supplies that were not used. * Unbundling of claims. This is billing separately for procedures that are covered by a single fee. * Double billing. This is charging more than once for the same service. * Upcoding. This is charging for more complex services than was performed. * Miscoding. This is using code numbers that don’t apply to the procedure. * Kickbacks. This is receiving payments for other benefits for making a referral. * Inappropriate or Excessive testing. This is billing for tests that didn’t happen or billing for tests that are more in depth then what was actually done. * Inflated pricing of drugs.
* Scheduling unnecessary patient visits.
* Self-referrals between physicians.
* False diagnosis.
* Using wrong modifiers.
Insurance companies can also be involved in medical billing fraud. Insurance companies sometimes hire medical billers and coders to help manage claims. The insurance company can have the billers and coders make adjustments or they can deny claims incorrectly so they can lower the payment amounts. In...
Please join StudyMode to read the full document