Medical coding and billing may be inherently noble professions but they’re no strangers to scams and frauds. In recent years, countless fraudulent firms have tarnished the reputation of these professions, leading to a range of misconceptions among the public.
As such, we consider it our moral responsibility to spread awareness about these scams so as to ensure our readers remain safe. If you operate a healthcare center and are about to bring a medical coder or biller on board, read this guide to steer clear of frauds and scams.
Scam #1 – Upcoding:
By far the most common scam plaguing the healthcare sector is upcoding. To understand what this is let’s consider the example of a patient who visits the local hospital to receive treatment for a sprained wrist.
Once the treatment is completed and the bill is generated, the insurance provider sees that the patient was billed for a broken wrist. Obviously, broken wrists cost more to treat than sprained wrists, but the healthcare provider gets to make more money in the process—fraudulently of course.
It goes without saying that any mismatch between the services offered and the services billed for is a federal offense and can leave your firm facing substantial lawsuits. To give you a ball park figure, the University of Texas Southwestern Medical Center had to pay a compensation of $1.4 million in an upcoding lawsuit back in 2011.
Scam #2 – Unbundling:
Most insurance providers try to save money by offering bundles (i.e. payment plans) for complementary medical services. For example, if you have a minor surgery coming up, then there’s a high chance that local anesthesia will be administered. As a result, the insurance company offers surgery bundles that cover the price of the anesthetic.
Now, a healthcare center could try to bill these services (the surgery and the anesthesia) separately which violates an existing bundle. This (theoretically) entitles clinics to higher reimbursements from insurance providers even though it’s a scam through and through. This deplorable act is called unbundling.
Scam #3 – Phantom Billing:
While upcoding can be written off as a typographical error or a genuine mistake, phantom billing is much more sinister in nature. This scam occurs when healthcare centers charge for medical services that they never performed to ensure that they receive higher reimbursements from their insurance providers.
That being said, it’s worth noting that not all firms that have been caught phantom billing did so out of malicious intent. In fact, there have been countless cases when healthcare center employees have mistakenly copied information from other patients (who actually opted for the services mentioned).
Whether done deliberately or mistakenly, phantom billing is serious a federal crime which can be avoided by opting for the services of a certified medical coder! The Allied Prep Technical Institute offers comprehensive medical billing and coding courses to our students so that they’re better equipped to avoid scams and offer ethical services.
We run a medical training institute that offers students and coding enthusiasts the medical billing and coding certifications – both on campus and online. Our rigorous tests and training programs ensure that our students always have the knowledge and the expertise needed to deal with complicated problems.