Whether it’s due to a mistake or intentional deception, medical coding errors are becoming a significant issue in modern medicine. When it comes to healthcare fraud, billing and coding errors are the most common forms. Honest mistakes can even be prosecuted under the False Claims Act. The charges could be either civil or criminal and come with some pretty severe consequences. Whether you’re a practitioner who has made a mistake or a patient who’s had an error made on his or her file, it’s often necessary to hire a healthcare fraud lawyer.
Before you dig through all of your old medical files, bills, and referrals, here is what you need to know about billing and coding errors:
Billing and coding errors count as healthcare fraud
There is a difference between an honest mistake and an intentional act of fraud. Because the Department of Justice, and other fraud-busting entities use computer algorithms to find cases of fraud, it is sometimes challenging to distinguish between accidents and deceptions.
Under the broad umbrella of medical coding and billing errors, there are two broad categories: fraud and abuse. Fraud is an intentional misrepresentation, while abuse is an innocent mistake. A new employee, for example, might misunderstand the coding system and bill for a more complex, thus more expensive service than was actually performed. While this kind of abuse can be forgiven, it can also create legal issues for those involved.
Solving problems of abuse often involves proper training and oversight. Since medical coding and billing is a complex organism, anyone working in this area must be adequately educated. It’s also vital to have some kind of system that helps audits the work that is being done. Employees who continue to make mistakes should be retrained, reassigned, or retired. The severity of medical billing errors is high enough that it should be taken seriously at every level.
Most common types of errors that are considered fraud
While errors resulting from abuse can be avoided with proper training and oversight, issues with fraud are more difficult to correct. Because fraudulent mistakes are made intentionally, it’s not an issue of misunderstanding but misplaced ethics. The challenge is that some practitioners may not know just what to look for.
As the most common form of fraud, upcoding is when medical providers bill for a more complex procedure than was performed. Upcoding often happens by accident, but can cause serious issues. A physician might be tempted to code for a more expensive procedure to meet office goals, earn bonuses, and more. Since insurance covers the bulk of the cost, the patient may never know the difference.
When components of a bundled package are billed separately, it is known as unbundling. In most cases, breaking apart a bundle results in a higher price. It’s similar to buying a burger, fries, and drink separately instead of lumping them together in a value meal. As with upcoding, it is possible that someone in billing didn’t realize that certain components are bundled together, but this method is also a way to charge extra than is necessary.
3. Coding the kitchen sink
Only a confirmed diagnosis can be coded. If a physician throws other codes into the mix, it is known as kitchen sink coding. When done intentionally, this practice is often done to make a doctor seem like he or she is treating more things in a visit.
The biggest challenge here is that kitchen sink coding could create a false narrative about a patient’s health. In some extreme cases, it could create a paper trail that shows a pre-existing condition. If that actual problem arises in the future, insurance companies could refuse to pay for treatment costing the patience exponentially more for relief.
4. Coding without consistency
If a patient’s diagnosis changes without the corresponding changes to symptoms or complaints, there is a consistency issue. These errors are often found when the procedures listed on the physician’s bill do not match what is located on the surgery center’s statement. Inconsistent coding is most likely to occur right before surgery or another procedure.
Medical billing and error results
Since insurance companies are footing the bill, you might wonder why it really matters if an error slips through here or there. So long as the patient doesn’t have to pay a more considerable out-of-pocket expense, is it that big of a deal?
Beyond being a federal crime, billing fraud has some other consequences. It may not just be the case of a big insurance company losing money. Here are some of the biggest, unintended consequences of billing fraud.
1. Patient care
Using the wrong code could change a patient’s care plan. A mere two-digit accident could result in an MRI being performed on the wrong area of a patient’s body. In a more extreme scenario, a patient could be denied certain medications because a miscode suggesting she is pregnant.
2. Delayed or Denied Reimbursement
Incorrect billing can cause insurance companies to delay or deny reimbursements. On the patient side, this could lead to a variety of issues. While insurance companies try to determine the accurate information, patients have to wait for funds for they may desperately need. In some cases, the entire claim is denied, forcing the patient to take action for an error they didn’t cause.
On the medical side of things, billing companies and doctor’s offices can be heavily fined for repeat offenses. A little upcoding here and there may seem like a simple way to meet your numbers but could end up costing the practice a great deal more down the road. The practice’s reputation may also be harmed so badly that you’ll find it difficult to get new patients or recruit talented doctors.
Read More: How to Choose a Health Care Defense Attorney
When in doubt, seek help
If you believe you’re on either side of medical billing or coding abuse or fraud, seek advice. An experienced healthcare fraud attorney can make a huge difference. Your lawyer can help your practice take the necessary steps to weed out intentional fraudsters. If you are a patient, your attorney can also make sure that coding abuse doesn’t slow down your reimbursement or taint your much-needed care. If nothing else, set up a free consultation to see if you’re in a position to seek legal help or defense. When it comes to your medical bills, there is no messing around.