As a medical office billing services when you are in residency likely aren’t focused on who will pay for the care of your patients. After you have started practicing it is essential to know who the players are. The U.S. healthcare system relies heavily on third-party payers which means that your patients may not be the ones paying for the majority of their medical costs. Third-party payers include commercial insurance companies as well as the Federal as well as State governments. 

Medical Billing Services

If you are a recipient of the Federal Government covers items or services provided for Medicare as well as Medicaid beneficiaries and beneficiaries, the Federal laws on fraud and abuse apply. A number of states have also adopted similar laws to your care through State-funded programs as well as for private-pay patients. Therefore, it is important to recognize that the topics discussed in this article could be applicable to the care of any insured patient. The issues covered in this article can assist you to avoid fraudulent billing when you are just beginning your medical practice.

Accurate Coding and Billing

Commercial and government payers depend on your expertise as a doctor who provides essential, cost-effective, and top-quality medical treatment. You have a significant say in the services you provide to your patients and you are in charge of the documentation that outlines what the patients actually receive. The payment by the government is usually based on the information you provide in claims documentation.

Because the government places the most trust in physicians at the front, Congress provided powerful criminal civil, administrative, and civil enforcement tools in instances where untrustworthy providers violate the trust. The government has the ability to review claims and investigate providers when it has the motive to believe that fraud has occurred. 

Let’s take a look at an example for charging Medicare as well as Medicaid. When you file claims for the services you performed to a Medicare or Medicaid beneficiary and you file bills to the Federal Government and certifying that you’ve earned the amount required and that you have complied with specifications for billing. One common fraudulent claim includes “upcoding,” which refers to billing codes that represent the severity of an illness more than was actually present or more costly treatment than offered. Other examples of fraudulent claims are:

• charging for services you didn’t in fact render;
• charging for charges that weren’t medically required;
• charging for services provided by an unqualified or by an unqualified employee
• charging for services carried out by an employee excluded from the Federal health insurance programs;
• charging for services with such low quality that they’re virtually useless as well as
• Separate billing for services is part of a global fee, for example, the cost of an evaluation or management services on the day following surgery.

Defining Upcoding

Medicare covers a variety of physician services with Evaluation and Management (E&M) codes. Visits for new patients generally take longer than follow-up visits for patients who are already established so E&M codes for patients who are new have greater reimbursement rates over E&M codes for patients who are already established. 

A typical example of upcoding is when you give the follow-up visit at your office or follow-up appointment inpatient; however, you bill with an upper-level E&M code, as if you were providing a complete new patient appointment or an initial consultation inpatient. Another instance of upcoding that is related to E&M codes is an infringement to make use of Modifier 25. 

Modifier 25 is a way to pay for a distinct E&M service that was rendered on the same day as an option. It is possible to upcode if a service provider employs Modifier 25 to obtain the reimbursement to cover an E&M service provided by a patient when the treatment provided was not substantial and was not identifiable separately and was not over and beyond what is normally related to the procedure.

Examples of Fraudulent Billing

Medcare Medical Billing Services (MSO) is a renowned medical billing business that offers full revenue cycle services. We provided important details taken from the Department of Health & Human Services Office of Inspector General (OIG) document on the education of providers. The original OIG document for a more thorough understanding. Since you are just beginning your practice, you may prefer to focus on patients instead of managing the administrative aspects of medical billing. We are able to manage all medical billing for your practice, while also avoiding fraud in billing. We offer billing solutions that are secure, affordable, efficient, and specific to the medical field you practice. Are you looking for all the benefits of third-party medical billing? To help you out, we are happy to provide medical billing and coding services to boost your revenue.