Explain What Constitutes Fraudulent Billing

Billing 1 Week 2 DB

Discuss the importance of knowing the processes and procedures used for receiving payment for services rendered under the contract provisions.

It’s extremely important to understand both the process and procedures of securing payment for medical services under a managed care contract agreement.

The process for receiving payment for services begins when the patient makes their initial appointment with a provider. The front office staff that registers the patient begins this process. During registration the patient provides their demographic and insurance policy information. The insurance carrier and type of policy that the patient has, will determine what the cost per services will be based on the terms of the contract

Everyone involved in this process must practice a high degree of accuracy and professionalism. Standards for the process will be found in any medical facility and it’s important to understand the process.

Discuss what constitutes fraudulent billing.

Several things are considered fraudulent billing practices. One is up coding. Using a code for a more expensive service when that was not the service rendered. Another is unbundling. Certain medical services are bundled together under one charge/code in unbundling you code the procedures separately which results in higher reimbursement. One you might not think of as being fraud is under-coding. This is often done to avoid investigation by the OCG.

Over coding and under coding depending on where the “idea” originates to do this can be akin to falsifying the medical record. So never ever allow a coworker or a provider to talk you into doing this even once.

References

All Things Medical Billing. (2015). Claim Process. Retrieved from