Towards Minimizing Legal Errors In Handling Medical Records

Despite such indicators from time to time, the incidence of legal errors has only been destined to move upwards. Physicians, whose core-concern being medical efficiency through best medical practices, cannot be expected of too much in this regard. Yet, because of it being integral to their practices’ sustenance and growth, its significance cannot be underestimated.

Notwithstanding physicians’ integrity in safeguarding medical information revealed by patients or discovered during the course of treatment, there have been instances of physicians running into legal issues on account of erroneous (though unintentionally) management of patient medical records. Irrespective of the intention, in view of adverse repercussions – severity of punishment ranging from civil charges (fines and suspension of practice) to criminal proceedings, including cancellation of practice license, and imprisonment – emanating from such erroneous management of patients’ medical information, it is advisable that physicians’ adhere to American Medical Association’s (AMA) ethical guidelines that govern the code of conduct on management of patient’s medical information; HIPAA guidelines are specifically formed and amended from time to time in this regard – the latest being the HIPAA 5010 scheduled to come into effect from October, 2013. Although AMA’s guidelines are not as legally binding as Federal or State-specific laws, yet – given the ethical nature of medical practice – judiciary has tended to being more approving of AMA’s guidelines. Therefore, physicians can deem AMA’s guidelines as the yardstick to measure their conduct of patients’ medical information.
Physicians can avoid committing the usual errors that have been identified over the years. Here are some of the frequent errors that physicians have tended to commit while handling patients’ medical information:

• Denying patients complete access to their medical records:
  Physicians have been reported to have presumed that their patients can be satisfied with partial access to their medical information. Though physicians have every right to withhold any information that may be damaging to a patients’ confidence or well-being, yet, in general cases, they should provide complete information as sought by their patients.
• Refusing to share a copy of the report with the patient:
  There have instances wherein Physicians have been summoned up by the law for refusing to share copies of medical reports with their respective patients. Therefore, it is a bounden duty of physicians to honor requests for copies of medical reports by their patients.
• Presuming that a non-custodial does not have a right to ask for a minor’s medical record: Proven wrong by the law (both Federal as well as State-specific), doctors should get rid of any such inhibitions as they might invite legal battles.
• Presuming HIPAA as the ultimate controller of patient information disclosure:
  Although HIPAA rules the roost in majority of cases, yet, there are areas where Federal and State-specific laws supersede HIPAA. Therefore, Physicians need to be mindful of parallel laws that work in tandem with HIPAA’s ethical guidelines for handling medical records.
• Honoring requests without being duly signed by the patients:
  Honoring requests of Data (PHI) sharing without being duly signed by patients can invite trouble if such requests happen to be unscrupulous. Therefore, physicians or their staff need to verify every request for patient signature, which is deemed authentic by Federal as well state-specific laws.
• Denying requests for records on account of unrealized fees from patients:
  While physicians have every right to realize their fees from patients, they cannot cite it as the reason for refusing request for records. Alternatively, they can only recover copying charges for such medical reports.
• Deeming it a right to charge patients for medical records:
  Although physicians have right to recover nominal fees for sharing copies of their patients medical records, they are not authorized to impose discretionary charges. At the most, they can include incidental charges such as postage and handling. The Federal as well as state-specific laws are very stringent on this. Therefore, physicians should avoid running into embarrassment for being unduly expensive.

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Despite such indicators from time to time, the incidence of legal errors has only been destined skywards. Physicians, whose core-concern being medical efficiency through best medical practices, cannot be expected of too much in this regard. Yet, because of it being integral to their practices’ sustenance and growth, its significance cannot be underestimated. Therefore, they need to source some kind of medico-legal advisory to mitigate the probability of committing errors in dealing with patient medical information.

With internal advisory proving either costly or ineffective, outsourcing seems to be the better option. Medicalbillersandcoders.com (www.medicalbillersandcoders.com), whose comprehensive medical billing management comes with a special feature dedicated to solve issues related to diverse situations in patient medical information handling, should offer physicians the much awaited respite from getting into legal tangle. The additional training to physician administrative staff and updates on billing and legal issues makes Medicalbillersandcoders.com the ideal platform for all physicians.

Alleviating the Time Factor in Evaluating Revenue Generation from Medical Claims

“While physicians would not mind investing in revenue optimizing systems, asking them to invest their invaluable time in something which is non-core to their medical efficiency could ultimately have an adverse impact on their efficiency for medical care. Therefore, there seems to be a considerable propensity to outsource Medical Billing Management”

The rapid healthcare reforms promulgated by the Federal Health Department have meant both unprecedented opportunities and threats for physicians across the United States. While the prospect of spiraling patient-base looms large, there also appears an element of apprehension over the effectiveness and efficiency with which they will be able to realize their medical claims amidst a reimbursement environment characterized by stringent audit-verifications. In fact, majority of physicians have expressed concern over unimpressive reimbursement rates despite investing heavily in compliant EHR, electronic billing and coding, and claim submission systems.

The bitter experiences have driven physicians to take stock of the situation, and evaluate their revenue generation from claim reimbursement against resource allocation. While physicians would not mind investing in revenue optimizing systems, asking them to invest their invaluable time in something which is non-core to their medical efficiency could ultimately have an adverse impact on their efficiency for medical care. Therefore, there seems to be a considerable propensity to outsource Medical Billing Management, which is believed not only to improve reimbursement rates, but also enhance the quality of medical care to patients.

Yet, amidst numerous service providers, the selection can often be tricky. Faced with such situation, physician should invariably conduct a SWOT Analysis of the shortlisted services providers for making judgment in favor of an apt service provider. Prior to soliciting a medical billing service provider, there is an underlying need to establish your service provider’s ability to provide comprehensive service package, comprising:

• Claim generation and submission
• Carrier follow-up
• Payment posting and processing
• Patient invoicing and support
• Collection agency transfer services

Further, you should also be able to figure out its ingenuity for amicable phasing of the billing management procedure – traversing a sequential pattern, such as credentialing, medical coding, transcription, insurance eligibility verification and appointment scheduling.


Additionally, the following criteria should usually form the basis for selecting a medical billing management company:

• Ability to provide highest level of service, which proves its capacity to pursuing denied claims, billing follow up, complying with regulations, and reporting and analysis of reimbursed claims.
• Substantial Industry experience, which validates its expertise in
• ICD9, CPT4 and HCPCS Coding
• Medical Terminology
• Insurance claims and billing, appeals and denials, fraud and abuse
• HIPAA and Office of Inspector General (OIG) Compliance
• Information and web technology
• Reimbursement
• Penchant for using the latest technological platforms, which verifies its sufficiency in EHR, billing software, coding technology, and online data repository service for data storage and dissemination across the network for interoperability.
• Pricing model adopted, which measures its flexibility to adopt result-oriented or project-based pricing systems.
• Receptive to new clients, which establishes its receptiveness to take on newer clients without any apprehensions.

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While these checklists are of immense utility to physicians seeking outsourced billing management solutions, the requisite comprehensive evaluation, yet again, involves time-factor of invaluable significance. Therefore, when faced with such daunting task involving intricate evaluation,

Medicalbillersandcoders.com (www.medicalbillersandcoders.com), whose comprehensive and proven Medical Billing Management – complete with accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards, should offer an easy recourse to instant selection.

Deciphering Medicare Fee Schedules

A proactive affinity to Medicare Fee Schedule alerts physicians to the efficacy of attending to Medicare beneficiaries, and also plans their revenue prospects in advance. But, with the legislation firm on mandatory medical service to Medicare patients, physicians are inevitably driven to seek and understand Medicare Fee Schedule.

The sheer volume of Medicare transactions (more than 50% of the total health insurance transactions in the US health insurance sector) is reason enough for physicians to understand the mechanism of Medicare payments from medical services provided to Medicare beneficiaries. Although the proposed inclusion of a substantial population into Medicare’s ambit should be a reason for celebration amongst practicing physicians, yet, the accompanying reforms that seek to economize and optimize Medicare payments should equally evoke anxiety among them. Therefore, given this unique situation of optimism and anxiety, physicians would be well-off with a proactive knowledge about Medicare Fee Schedule.

As Medicare Fee Schedule – which decides on the reimbursement to be allowed to Medicare providers for different services, and restricts the amount a non-Medicare provider could charge a Medicare patient – is the governing fee schedule promulgated by the Federal Legislation for both Medicare and non-Medicare providers, there is a growing significance of being knowledgeable about the likely reimbursement from attending to Medicare patients. Such proactive affinity to Medicare Fee Schedule alerts physicians to the efficacy of attending to Medicare beneficiaries, and also plans their revenue prospects in advance. However, with the legislation firm on mandatory medical service to Medicare patients, physicians are inevitably driven to seek and understand Medicare Fee Schedule.

Further, there are several prevailing factors that contribute to differential reimbursements to providers despite providing similar services under Medicare fee schedule. Usually, such cases can be found if the hospital is a teaching hospital, or if it cares for a disproportionate share of indigent patients, or if the facility is located in an area with a higher cost of living.

Amidst this complex Medicare Fee Schedule regimen, the following ready-reckoner released by the American Medical Association (AMA) should be comforting for physicians:

The current ready-reckoner works on the geographic adjustment provisions of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89), which requires all three components of the relative value for a service – physician work relative value units (RVUs), practice expense RVUs, and professional liability insurance (PLI) RVUs — to be adjusted by the corresponding GPCI for the locality. Effectively, the sweeping provision has increased the number of components in the payment schedule from three to the following six:

• Physician work RVUs: better known as Physician Work Relative Value Units
• Physician work GPCI: better known as Physician Work Geographical Practice Cost Index
• Practice expense RVUs: better known as Practice Expense Value Units
• Practice expense GPCI: better known as Practice Expense Geographical Practice Cost Index
• PLI RVUs: better known as Professional Liability Insurance Relative Value Units
• PLI GPCI: better known as Professional Liability Insurance Geographical Practice Cost Index

The comprehensive general formula for calculating Medicare payment amounts for 2011 is arithmetically expressed as:
Work RVU1 x Work (GPCI)2
+ Practice Expense (PE) RVU x PE GPCI
+ Malpractice (PLI) RVU x PLI GPCI
________________________________________
= Total RVU
x CY 2011 Conversion Factor of $33.9764
________________________________________
= Medicare Payment 

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But, given the intricacies involved in computing resultant payments, physicians would be hard-pressed for time and resource, which otherwise could be diverted to the most crucial aspect of their core services: keeping their medical efficiency benchmark improving. With the current dynamic changes in the healthcare scenario, the proven capabilities of Medicalbillersandcoders.com (www.medicalbillersandcoders.com), the largest consortium of medical billers and coders in the US, in imparting the crucial knowledge on Medicare Fee Schedule as part of its comprehensive Medical Billing Management is also an useful option for healthcare providers.

The Relevance of Using Perfect Modifiers in Medical Claims

The overlapping nature of certain medical procedures is such that it is impossible to report them with CPT codes alone. Although CPT coding has grown to be comprehensive enough to cover breakthrough procedures over the years, yet, physicians are not spared from submitting separate procedural forms for medical procedures requiring explanation that overshoot the CPT boundary. Recognizing a parallel system that not only obviates the necessity of submitting supplementary forms but also expedite the submission and realization of medical claims, American Medical Association (AMA) has long been known for promulgation of modifying those overlapping medical procedures through unique and efficient Modifiers, identified and approved for the very purpose of aiding physicians in successful submission and realization of medical claims for their medical services to the patient fraternity. Thus, physicians, having a unique recourse to their problems in medical billing, should be competent enough to not only know the definition of Modifiers but also the circumstances wherein they can apply them.

AMA defines Modifiers as codes that are used to “enhance or alter the description of a service or supply” under certain circumstances. From this definition, it can be inferred that modifiers provide the means by which the reporting physicians can indicate that services or procedures that have been performed have been altered by some specific circumstance but has not changed in its definition or code. Thus, modifiers can be attached along with the originally billed and coded forms, without being required to submit through separate forms. Further AMA has also identified the following circumstances that warrant the application of modifiers:

• a service or procedure which has both a professional and technical component
• a service or procedure which requires to be performed by more than one physician and/or in more than one location
• a service or procedure which has been increased or reduced
• a procedure wherein only part of a service is performed
• a procedure wherein an adjunctive service is performed
• a procedure wherein a bilateral procedure is performed
• a service or procedure which is provided more than once
• a procedure wherein rare events were witnessed

Having understood the circumstances and the extent to which modifiers can be applied during the course of preparing and submitting medical claims, physicians should also be conversant with the prevailing and acceptable modifiers that are unique to their individualistic practice specialties. Generally the following set of modifiers are frequently used and accepted by the insurance carriers:

• Modifier-25: needs to be attached with any evaluation management service done on the same day by the same physician. Further, the procedure needs to be beyond the usual preoperative and postoperative encounter.
• Modifier-24: can be used with any unrelated evaluation and management service by the same physician during postoperative period, and, like modifier 25, has no restriction as with the level of E/M code as long as it meets medical necessity. Also, all its components are time-based.
• Modifier-57: allowable when an evaluation and management service results in the initial decision to perform surgery.
• Modifier-50: allowable with bilateral procedure performed on the same day, during the same operative session, and on identical anatomical sites. Further, it can be used with add-on codes also; but cannot be used with procedures that are already described as bilateral procedures.
• Modifier-51: handy while reporting multiple procedures performed by the same physician on the same day. But, it can be clubbed with the procedure done on the same day by another physician.
• Modifier-59: necessitates reporting any distinct procedural service performed on the same day that is deemed apt under a medical situation. But, the physician needs to establish the need for such distinct or independent service while appending with the original procedure.
• Modifier-26: As certain procedures are combination of both professional and technical component, this modifier is useful while reporting the service as a professional component only.

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Although the Modifier System is comprehensive enough to mitigate all challenges while coding and submitting medical claims, the voluminous knowledge accompanying it would be hard to be digested by the physicians, who have a much more challenging task of keeping their medical practice benchmarks unblemished.

Fortunately, they can look forward to proven outsourced solutions on the horizon. Medicalbillersandcoders.com (www.medicalbillersandcoders.com), with a comprehensive outlook to their clients’ billing and coding management and with substantial hands-on experience across specialties, is uniquely poised to advise, own, and execute an efficient system of modification as part of its all-inclusive medical billing management.

Group Appointments: A new niche for Primary Care Practice

Group appointment, also referred to as shared medical appointment, includes multiple patients seen as a group for follow-up or routine care. These visits are voluntary for patients and provide a secure but interactive setting in which patients have:

• improved access to their physicians,
• the benefit of counseling with additional members of a health care team (such as a behaviorist, nutritionist, or health educator), and
• share experiences and advice with one another.

According to the AAFP, Group Appointments were utilized by around 6% of family physicians to provide some amount of patient care in 2005, and that number has gone up to 13% in 2010. Group medical appointments are also a key component of the patient-centered medical home (PCMH) model. There are three general models for the shared medical appointment:

• The cooperative health care clinic (CHCC), created for older patients requiring frequent, broad-spectrum care;
• The disease-specific CHCC, a diagnostically exclusive group that aids patients with chronic-disease management; and
• The drop-in group medical appointment (DIGMA), intended for established patients requiring a more comprehensive approach to their follow-up care.

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Medicare generally pays for group visits if there is some one-on-one time with the physician, but practices should contact local carriers and other insurers about their policies; some carriers are still resistant to the idea. 

Who benefits from this type of program?
Shared medical appointments can be satisfying to both the physician and the patient, used as substitution or in addition to a traditional appointment. They are most appropriate for patients requiring routine follow-up care, or frequent time with the physician, or chronic patients. They can offer an increase in the productivity and efficiency of the health care team as well as enhance the patient’s visit by offering a holistic and therapeutic approach. 

Staff
Group appointments might require trained staff to act as facilitators, or even especially experienced billers and coders who are able to understand the process of group appointments, in order to get proper reimbursement for the providers, although physicians can outsource billing assistance for such appointments to professionals who are trained and experienced in group practice billing.

Implementing an Ideal EMR System for Your Practice

“Judging from the evidences of successful EMR implementation, customization has been the pivotal element, and will hold good for future also. Taking cue from such references, practices can benefit immensely, and successfully mitigate the probability of misadventure”

More than the mandatory obligation of digitalizing/computerizing/electronically recording healthcare data, it is the overwhelming benefits over investment outlay that have convinced physicians, clinics, hospitals, and multi-specialty groups of the efficacy of implementing Electronic Medical Recording (EMR) in their practices. But, implementing the EMR systems that best serves your individualistic needs is not as easy as arriving at the decision to implement it. In fact, there have been instances of unsuccessfully implemented ventures at it. Therefore, presuming EMR to be universal, and leaving your EMR implementation to your vendor’s discretion could prove to be a costly error.

Judging from the evidences of successful implementation, customization has been the pivotal element, and will hold good for future also. Taking cue from such references, practices can benefit immensely, and successfully mitigate the probability of misadventure. The following pro-active approach should be a guiding light in the search of an effective and efficient Electronic Medical Recording System Implementation:

• Defining your needs:
  The first step to an effective and efficient EMR system is an internal analysis leading to a clear definition of your needs in terms of scope and volume of data capture. Such an internal analysis aids in preparing an amicable budget outlay for your individualistic EMR system implementation.
• Spelling out your hardware and software requirements:
  Having defined your needs, you should be able to clearly spell out your hardware and software requirements in line with your scope and volume of data capture needs. Doing so can cut out unnecessarily over-installing your capacity at an exorbitant cost.
• Short listing vendors: In a market characterized by vendor-oligopoly, selection becomes tricky. Therefore, it is desirable that you prune down the list depending on vendors’ relative credentials. Being an important exercise on the way to successful implementation, this can be crucial in avoiding a wrong choice of vendor.
• Arranging for demo: A preliminary demonstration of EMR Systems can reduce your apprehension over their capability. Therefore, it is advisable that you are presented with demos by short-listed vendors.
• Confirming on pre and post installation training: Mere installation would not serve your purpose comprehensively; ensuring proper orientation of your staff to the technology assumes greater significance. Therefore, your vendor should be able to provide for such orientation.
• The extent of post installation services: Like your vendor’s capability for providing pre and post installation orientation, their promise for extensive after-sales service is also an important consideration prior to choosing an EMR system for your practice.

The fore-play of these factors is likely to pose mounting challenges to physicians, who may lack the foresight on something that is not their core competence. Inevitably, they would need to seek out help from Medical Billing Management Service providers.

Medicalbillersandcoders.com, with a wealth of knowledge on advising medical fraternity with proven solutions in Medical Billing Management – technology interface for seamless reporting of medical data being one of their niche solutions – should be an ideal ally in helping to choose the best EMR System mapped to your unique needs, ensure your practice in congruence with Federal Healthcare Mandate for EMR, and even make your practices eligible for incentives for meeting the Best Practices in Electronic Medical Record System.

Hospitalists registered a pay increase in 2010

The year 2010 has registered a hike in the median compensation for Hospitalists. The Hospitalists in adult medicine saw their compensation increase 2.6% to $220,619 from $215,000 while the Pediatric Hospitalists’ pay rose by 7.2% to $171,617.


The report, which is based on MGMA survey information, takes into account data from 4,633 hospitalists in 412 groups and 726 academic hospitalists in 68 academic medicine practices. The pay also varied region-wise; the median compensation for southern hospitalists was higher as compared to west, Midwest and eastern region, that is, $235,701, $231,831, $211,751, and $205,000 respectively.


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One of the reasons for the hike in compensation is the increase in hospitalist productivity; hospitalists are being recognized for their value in other arenas, as it relates to the transition from the fee-for-service to pay-for-value-type models, championing effective transitions of care, leading process improvement teams, etc. Another reason for the rising trend in pay is the fact that the demand for hospitalists has exceeded the supply.
Another potentially significant variable that could strongly impact the future trends in the Hospitalists’ salary is the drastic healthcare reforms and regulations sweeping the industry.

Medicaid claims audits slated for January

The Medicaid recovery Audit program is due to get implemented nationwide in January, carrying on in a similar vein as Medicare RAC program, as announced by CMS on 14th September, 2011. The Medicare RAC had recovered $451.3 million in overpayments and corrected $78.5 million in underpayment within six months in 2011.

The Dept. of Health and Human Services estimates that Medicaid RACs will save the program $2.1 billion over the next five years, of which $900 million will revert to the states. The states must implement Medicaid RACs by Jan. 1, 2012, according to the final ruling.

The states will enter into a contract with the Medicaid RACs, which will review the past claims that have already been paid and scrutinize them for fraud, waste and abuse. The auditors will be recompensed by getting a percentage of the funds they recover as having been inappropriately paid to doctors, hospitals and others. However, AMA has indicated its discomfort over the fact that RACs will be paid on the basis of their recoveries.

At the same time, the final rule also directs states to pay reviewers for uncovering underpayments that must be reimbursed to those filing the claims.

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The CMS has incorporated certain points in the Medicaid Audit program which were not present in the Medicare Audit program:

• Each Medicaid RAC must hire a physician as medical director
• The CMS has called upon the states to place a limit on the frequency and age of claims that Medicaid RACs can request from claimants for review
• Requiring states to coordinate their Medicaid RAC activities with those of other auditors; RACs cannot audit claims already being investigated by another entity
• Requiring RACs to return their fee if an overpayment determination is reversed at any level of appeal

The audit program is likely to aggravate the reimbursement as well as administrative burdens of the providers. Overall a need has been expressed for the CMS to take effective measures to educate providers as well as other health professionals to pre-empt inadvertent coding mistakes and the consequent incurring of penalties. In fact, these issues once again underscore the wisdom in utilizing trained and experienced billing and coding professionals well versed in handling RACs audits to pro-actively avoid auditor scrutiny.

How crucial will medical billers’ role be after healthcare reforms?

“Proactively realizing the need for preparing to face up to these challenges, many professional medical billing companies have taken up upgrading their system and human capabilities to the probable demands emanating from healthcare reforms”.

A string of healthcare reforms announced by the Federal Government over a year or so have changed the landscape of the healthcare industry nationally. The expected extension of insurance coverage for more than 30 million people, removing pre-existing condition clause, and an incentive based healthcare regime are going to influence and alter the equation for all the stakeholders concerned, more so the medical billing management companies/professionals. While the extensive coverage of health insurance should open avenues for more business and revenues, the ensuing stringent billing regimen – the mandatory EMR System Implementation, ICD-10and HIPAA 5010 compliant coding and reporting norms, and highly rigid insurance carriers – is going to test Medical Billers’ ability to adapt to the changing landscape. Never before has the role of medical billers been more debatable than now.

As the healthcare reforms take effect, Medical Billers will be called upon to redefine their role in as far as:

• Ensuring compliant EMR Systems for physicians: As a seamless EMR System is the foundation for apt medical coding, medical billers will be called upon to advice their clients’ on the efficacy of implementing EMR System as part of their effective and efficient medical billing management.

• Upgrading their competence to ICD-10 and HIPAA 5010: As the new coding and reporting regimen takes over shortly, medical billers – to avoid being outdated and obsolete – need to make a successful transition to the ensuing ICD-10 and HIPAA 5010 requirement.

• Helping physicians on public and private insurance composition: With the healthcare reforms deciding to minimize reimbursement on Medicaid and Medicare policies, physicians/hospitals are rethinking on what should be the composition of public and private insurance holders in their patient population. Consequently, medical billers’ role assumes greater significance in recommending a judicious mix of public and private health insurance holders in their clients’ patient population.

• Establishing a mutually respectable relationship with insurance carriers: Forging a cordial relationship can go a long way in ensuring fast, and delay free reimbursement of physcian’s medical bills; medical billers would do well to build a rapport with heterogeneous insurance carriers.

• Educating physicians about internal preparation for medical billing: Apart from ensuring a compliant system of billing, submission, and realization, medical billers will also be called upon to educate physicians about the efficacy of upgrading internal system of data recording and filing for complimenting comprehensive needs of medical billing management.

• Approaching Medical Billing as a wholesome exercise: Above all, medical billers will be asked to view physician’s medical billing from a complete revenue cycle management perspective rather than one-off billing exercises. Such a comprehensive approach improves the probability of positive outcomes immensely.

Proactively realizing the need for preparing to face up to these challenges, many professional medical billing companies have taken up upgrading their system and human capabilities to meet the probable demands emanating from healthcare reforms. Likewise, Medicalbillersandcoders.com – known for its proven medical billing solutions to a majority of physicians, hospitals, clinics, and multispecialty groups across the whole of U.S – has taken up advancing their system and human capability on a massive scale. With their vast hands-on experience on innumerable projects, and updated knowledge of healthcare regulations and IT, our MBC billers and coders bring a plethora of value-added services to enhance your processes and RCM.

Combating Healthcare Fraud and Abuse – a challenging task for providers

The inherent nature of Health Insurance is such that it is highly susceptible to fraud and abuse by unscrupulous healthcare providers and beneficiaries. Consequently, there has been an unbridled rate of fraud and abuse amounting to billions of dollars – a reliable statistics puts it around 300 billion dollars, and still counting. Whereas, primarily, it is a staggering erosion of Private and Federal Government’s Health Insurance Funds, it has wider repercussions: payers, employers and patients having to pay higher premiums, lower benefits, higher taxes and higher copayments on account of rising cost of health benefits, necessitated by unethical erosion of healthcare insurance funds.

While there have been regular reforms – medical billing and coding compliances such as EHR System, CPT coding regimen, and HIPAA compliant medical reporting, auditing programs – for checking this burgeoning problem, yet, insurance carriers are unable to shield themselves completely from this menace. The duality of this menace further compounds the issue:

Duality of Fraud and Abuse of Health Insurance Schemes
Fraud by Beneficiaries of Healthcare Providers Fraud by Healthcare Providers

• Using a member ID card that does not belong to that person
• Billing for services that were not provided
• Adding someone to a policy that is not eligible for coverage
• Duplicate submission of a claim for the same service
• Failing to remove someone from a policy when that person is no longer eligible
• Misrepresenting the service provided
• Doctor Shopping – visiting several doctors to obtain multiple prescriptions
• Upcoding – charging for a more complex or expensive service than was actually provided
• Billing for a covered service when the service actually provided was not covered

What is more alarming is that these dual entities have the propensity to collude and operate through an unholy nexus. Faced with such imminent threats, it is high time that health insurance providers implemented an effective program that can detect, investigate, prevent, prosecute, and recover the loss of corporate and customer assets resulting from fraudulent and abusive actions committed by providers, members, groups, brokers, and others. Although RAC audits have been able to recover a substantial amount of fraudulently claimed reimbursements, still, a considerable number of cases find ways to sneak in under their nose; the high cost of appointing Recovery Audit Contractors (RACs) – nearly ¼ of the total reimbursement to be audited for fraudulent realization – is not helping the cause either.

But, in the face of radical health care reforms – Affordable Care Organizations, proposed cuts to Medicare, and the negative impact of imminent Sustainable Growth Rate backlash – Federal Government’s Medicare and Medicaid – which account for a major share in the nation’s healthcare insurance scheme – along with major private insurance carriers, have the monumental task of safeguarding against adverse impact of health insurance frauds and abuse including higher premiums, lower benefits, higher taxes and higher copayments.

The scenario warrants these providers to either build or outsource proven anti-fraudulent measures that can ensure a profit-building model through raising premiums or adding new members. Such anti-fraudulent measures assume greater weight when they are faced with the undesirable prospect of erosion of their funds by 10% to frauds and abuse. With historical experience of internal anti-fraudulent measures leaving a lot to be desired for, recourse to proven agencies that have demonstrated optimum efficiency in anti-fraud measures and recovery rate is recommended.

Medicalbillersandcoders.com – having the distinction of being the largest medical billing consortium, and advisory to many insurance carriers – should be of immense help in this regard. With their exposure in billing and coding across specialties and payers, and expertise in all billing issues related to the latest compliances and regulations, their consultancy services can assist in scrutinizing inadvertent billing and book-keeping oversights, and pro-actively minimize compliance exposure by healthcare providers.