General Medical Billing Frauds in Healthcare Practices

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General Medical Billing Frauds in Healthcare
Practices

• Spending on healthcare in the US is intensive as
  healthcare spending grew 4.6 percent in 2019,
  reaching 3.8 trillion or 11,582 per person.  As
  a share of the nations Gross Domestic Product,
  health spending accounted for 17.7 percent.
  However, an important fraction of this money up
  to 10 of total health expenditure is wasted
  because of fraud and abuse, amounting to billions
  of dollars per year. Hence general medical
  billing fraud in healthcare practices is a
  must-know fact.
• Healthcare Frauds
• Healthcare fraud occurs when an individual, a
  group of people, or a company knowingly
  misrepresents or misstates something about the
  type, scope, or nature of the medical treatment
  or service provided, in a manner that could
  result in unauthorized payments being made.
• General Medical Billing Examples of Healthcare
  Fraud include
• Billing for services not rendered
• Billing for a non-covered service as a covered
  service
• Misrepresenting dates of service
• Misrepresenting provider of service

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General Medical Billing Frauds in Healthcare
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• Waiving of deductibles and/or co-payments
• Incorrect reporting of diagnoses or procedures
  (includes unbundling)
• Overutilization of services
• These types of healthcare frauds can be
  implemented against Medicare, Medicaid, Blue
  Cross Blue Shield, workers compensation, and
  other private entities. We will look at each
  fraud in detail in the latter part of the brief.
• Medicare Service coverage for General medical
  billing
• You should understand Medicare services to know
  frauds better. Medicare services are divided into
  Part A and Part B coverage where Part A covers
  hospital care, home health care, and skilled
  nursing care while Part B covers physician
  services, laboratory tests and x-rays, outpatient
  services, and medical supplies.
• General Medical Billing Frauds in Healthcare
  Practices
• Billing for services not rendered
• It is a general and most common fraud where the
  medical provider or its facility submitted claim
  forms to

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General Medical Billing Frauds in Healthcare
Practices
insurance companies for services and care that
were never provided, and the corresponding
patient files had no supporting documentation.
Physicians might throw in some extra dates and
codes on the claim forms to try to make some
really easy money. In a second scenario, gang
visit, can cause fraud. When a provider visits a
nursing home and bills for services as if they
had treated most of its residents. Alternatively,
a provider may perform a service regardless of
whether each resident needs it. Hence providers
should take a closer look while billing and bill
only for services rendered or goods
provided. Billing for a non-covered service as a
covered service Billing for services that are
not covered by government health care plans or
other insurance companies, for example, the
doctor is providing a treatment, which was
considered experimental and therefore not
approved by government health care plans or other
insurance companies then the doctor submitted
claim forms and still got paid for utilizing the
experimental treatment. The doctor accomplished
this by coding something else that was covered by
insurance plans and policies. Hence you should
look for what services are covered under
insurance plans and bill accordingly.
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General Medical Billing Frauds in Healthcare
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Misrepresenting dates of service The provider
can cause this fraud by reporting visits and
treatment of the same patient on two separate
days rather than one day to make quick money. In
this type of fraud, claimed services are
provided. But the dates are false because its
more profitable for the providers. Misrepresentin
g provider of service This kind of fraud is very
dangerous where different people impersonate a
physician and bill for treatment but
lesser-educated mental health professionals
conduct the therapy in reality. In these cases,
the affected insurance companies would still have
paid for the care provided by the less-educated
therapists (as long as they were licensed), but
they would have paid less. Hence you should avoid
such fraud to prevent revenue leakages. Waiving
of deductibles and/or co-payments Some providers
do waive patients deductibles or copayments
however most government health care plans and
insurance companies are against it and dont
allow medical providers or facilities to waive
patients deductibles or copayments as it may
lead to fraud for example- Some providers do
waive patients deductibles or
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General Medical Billing Frauds in Healthcare
Practices
copayments and then submit other false claims to
insurance companies to make up the dollar
difference by adding a bunch of other false
services to the claim forms to increase their
illegal gains knowing that the patients are
unlikely to complain because their copayments and
deductibles were waived. Incorrect reporting of
diagnoses or procedures (includes
unbundling) When providers submit separate bills
for lab services that combine three or four
tests, which are intended to be billed as one
service, in return Medicare pays the provider
more for each service instead of a group of
services. Overutilization of services Alcohol
and drug rehabilitation facilities are ripe for
overutilization as providers use this scheme on
hypochondriac patients. Tests and exams can go on
indefinitely or at least as long as a patient has
coverage or can make payments. You can
say general medical billing frauds in healthcare
practices are the same as other industry frauds
and fraudsters are always looking for an
opportunity to take full advantage to unjustly
profit. However, every stakeholder in the
healthcare system should avoid fraudulent
behavior to avoid further consequences.
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General Medical Billing Frauds in Healthcare
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If you want to make your medical billing clean
and avoid claim denials, then you can email us
at info_at_medicalbillersandcoders.com or call us
at 888-357-3226. We are HIPAA-compliant
professionals to make your claim submission easy
and clean.
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General Medical Billing Frauds in Healthcare
Practices

• FAQs
• What is healthcare fraud in medical billing?
• Healthcare fraud occurs when healthcare
  providers, organizations, or individuals
  intentionally misrepresent services or treatment
  to receive unauthorized payments from insurance
  companies or government programs like Medicare
  and Medicaid.
• 2. What are common examples of medical billing
  fraud?
• Some common examples include billing for services
  not rendered, misrepresenting dates of service,
  waiving deductibles or copayments, incorrect
  reporting of diagnoses or procedures, and billing
  for non-covered services as covered.
• 3. How does billing for services not rendered
  constitute fraud?
• This fraud happens when providers submit claims
  for services never provided to patients. The
  provider may add false dates or services to claim
  forms, generating revenue without delivering any
  actual care.

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Practices
4. How does misreporting diagnoses or procedures
impact medical billing? Misreporting diagnoses
or unbundling procedures involves submitting
separate claims for services meant to be billed
as a single group. This inflates costs and
increases reimbursements, defrauding insurance
programs like Medicare. 5. Why is waiving
deductibles or copayments considered
fraudulent? Waiving a patients deductible or
copayment may seem helpful, but many government
and private insurers consider it fraud. Providers
may inflate claims with false services to
compensate for the waived amount, resulting in
illegal gains.