In America, the annual spending on the healthcare industry amounts to around $2.7 trillion, taking
up about 17% of the country’s GDP. Despite several efforts by the federal and state authorities to
give the patients the best possible experience with an excellent clinical outcome and manageable
costs, fraudulent activities in RCM medical billing are always on the increase. It is also true that
not all charges against the provider organizations are accurate. At the same time, in some cases,
billing teams make specific clerical errors without any ill intention, which surmount fraudulent
charges.
Whatever the case might be, healthcare organizations spend up to $272 Billion every year all over
the country to settle these fraudulent charges in RCM medical billing. Provider organizations must
keep their billing teams updated on the latest modifications in billing regulations and try to
eliminate clerical errors to ensure that their financial health is not harmed. Know how minor errors
in healthcare billing lead to multi-billion dollar lawsuits, which red flags you should notice, and
how you can avoid them.
Common Illegal Practices in RCM Medical Billing
Most of the time, the fraudulent billing practices are easy to notice but are often ignored by the
professionals due to a lack of awareness. Hence it is crucial to hold regular pieces of staff
training to inform them of these errors. Here are the most common issues of RCM medical billing
which lead to fraud charges.
Upcoding:
Upcoding is when a provider submits codes to the insurance panels for more severe diagnoses than
they actually diagnosed. This is the most common illegal practice in RCM medical billing that finds
its place in complaint charts. The wrongful overpayment from the insurance panels is later realized
through the higher premiums paid by the patients.
Upcoding also poses a severe health-related consequence for the patients. As more severe and
complicated health conditions are recorded on their account due to upcoding, any health condition
management might become unnecessarily complex in the future, leading to further wrongful diagnosis
and treatment.
Over-prescription of Drugs and Tests:
A section of primary care physicians and patients often complain about being burdened with excessive
drugs and investigative tests than actually required. Most of the time, providers practicing these
methods prescribe more expensive medications or refer complicated tests to increase the bill amount.
Some of the standard tests prescribed by the doctors are MRIs and CT Scans for minor headaches. Some
others are Non-Stress Tests and EKGs for investigating any heart health issue. Primary care
physicians believe that these tests often produce inconclusive reports leading to recurring tests
and medicines. These ultimately lead to an increase of medical bills of the patients, without any
proper clinical outcome.
Unbundling of codes:
Unbundling of codes can lead to medical bills doubling up for the same procedure when done together.
While this is one common cause of contention between insurance companies and provider organizations,
it might also happen due to a lack of proper coding knowledge.
Many inexperienced coders or misguided providers might code the procedures separately though they
can be easily put under the same umbrella. This practice leads to unethical inflation of the medical
procedure, leaving the patients with a larger bill than needed.
Miscoding for Uncovered Treatment:
Providers with fraudulent intentions might miscode a service that was never performed to cover for a
service that the insurance panel of the patient does not cover. This is an outright unlawful
practice that should be dealt with strictly.
It is imperative to check the bills and discuss the health plan’s coverage well in advance before
performing any procedure. These complaints in the court of law could lead to multi-million lawsuits
for the organization.
Increased RCM Medical Billing Frauds in Medicare and Medicaid
Attorneys dealing with healthcare billing fraud lawsuits say that they have seen an increase in
these cases for Medicare and
Medicaid patients rather than private insurance. Funded by the taxpayer’s money, this has become a
critical case for the medical billing ecosystem.
Experts think that the vast size of the population under Medicare and Medicaid insurance is one of
the most common reasons for the easy attacks in these schemes.
According to the annual numbers released by the CMS, Medicare spends around $600 billion for
healthcare claims while state-sponsored Medicaid provides a cumulative budget of approximately $450
billion every year.
Under Medicare, around 4.5 million claims get processed every day. However, as few as 1% of them get
adequately audited.
The administrative neglect combined with the massive volume of claims under the Government-sponsored
programs makes Medicare and Medicaid easy targets for fraudulent practitioners.
How to Avoid Accidental Billing Errors
Even severe errors in healthcare billing might occur accidentally or due to a lack of updated
billing and coding knowledge. However, when kept unattended for a long time, it can lead to
challenging legal hassles for the provider organization. Here are some ways professionals at leading
revenue cycle management companies can help you:
Billing professionals at RCM Billing companies keep themselves up to date with the latest guidelines
issued by federal healthcare agencies.
They also use automation software solutions to eliminate any possible manual errors that might have
occurred during the posting process.
Experienced RCM billing companies conduct staff training sessions for in-house billing teams in
provider organizations to keep them updated on the best billing and coding practices.
Professional teams also follow proven models of scalable practices to help you keep legal hassles at
bay as well as optimize the billing operations to give the best results.
Experts advise provider organizations to train their coding and billing staff well to ensure they do
not make any errors that could lead to fraudulent charges.
You can get in touch with RCM medical billing companies to get your financial health evaluated and
check how you can safeguard your organization from any such issues in the future.
We hope this article helped you understand how the fraud charges work in RCM medical billing and how
you can avoid them. If you have any questions, write to us in the comment section. Subscribe to our
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