Revenue Cycle Insider

Training your office staff and correctly billing patients is key to avoiding fraudulent claims.

Edna Maldonado, ACS-UR, CPC, discussed the importance of performing internal audits to help prevent fraud within your office during her session “Detecting Potential Fraud” at HEALTHCON Regional 2024 in Philadelphia.

Read on to learn how to protect yourself and your practice from being flagged for fraudulent claim activity.

What Is Medical Billing Fraud?

Definition: Medical billing fraud is the intentional deception or misrepresentation in billing to receive unauthorized benefits.

Common types of medical billing fraud include:

• Upcoding: Billing for more expensive services than those provided
• Unbundling: Separately billing for procedures that should be billed together
• Phantom Billing: Charging for services that were not provided
• Duplicate Billing: Billing multiple times for the same service
• Overutilization: Providing unnecessary services to increase payment

In the past, patients tended to trust the system more than they do today. Maldonado stressed that many fraudulent cases or claims are flagged by the patient, not necessarily the payer. “Today patients actually do read through their EOBs [explanations of benefits], and they will reach out and ask for some investigation, if necessary,” said Maldonado. “I always tell the provider: ‘We need to support the CPT^® code with the procedure that was done.’” Sometimes you need to educate the provider to avoid unintentionally or unwittingly committing fraud, whether that’s by choosing an incorrect CPT^® code or via bundling that was done incorrectly. 

Avoid Being Flagged for Potential Fraud

Maldonado warned that coders and billers can help prevent having their claims and offices flagged for potential fraud by watching for incomplete or inconsistent medical documentation, or missing or incomplete medical records. By making sure medical documentation is complete and accurate, you can prevent a huge unnecessary headache for your practice. “Have good communication with your providers. Whenever you are reading an operative report and something is missing, reach out to that provider right away to get that missing information,” she said.

Also be aware of patients stating they were billed for services that they did not receive, even in the case of something as simple as being given a painkiller after a procedure. If they truly didn’t receive it, your practice obviously can’t bill for it without the service being fraudulent. Keep an eye on codes that are frequently being billed in your office; you will want to watch out for “unusual billing patterns like a high frequency of certain codes and an excessive use of high-paying ones,” said Maldonado.

Run Internal Audits

Maldonado explained the benefits of running internal audits include:

• Keeping coding and billing errors in check and helping identify incorrect coding, but also preventing incorrect coding from being repeated
• Uncovering areas of noncompliance and resolving ignorance as a liability
• Illustrating why the practice is responsible for detecting inappropriate coding and billing practices

Maldonado suggested that even if you don’t have the time to do an internal audit, you should consider paying someone to come in and do one.

“There should be someone within the practice auditing you and the other coders. Unless there are continuous errors on the same things we discuss over and over, it shouldn’t be a disciplinary issue,” she said.

There are many different types of audits that can be beneficial to your practice:

• Internal audits: These are conducted by internal staff to ensure adherence to internal policies and procedures
• External audits: These are conducted by third parties to provide an objective assessment
• Prepayment audits: This is a review of claims before payment is made
• Post-payment audits: This is a review of claims after payment has been made to detect overpayments or fraud

Maldonado also warned against underpaid staff being tempted to “help themselves” when cash is being handled at the front counter. She advised that you “review your daily cash logs and make sure they are accurate. Who is receiving the mail and electronic payments? Are they being posted correctly?”

To prevent any discrepancies at the front end with collection of cash payments from patients, she suggested the following: ensure proper collection and recording of patient payments, review daily cash logs and payment receipts, verify that payments are accurately posted to patient accounts, and ensure adherence to payment collection policies.

Coach Staff When Necessary

It’s crucial to ensure that coding and billing errors are minimized and that any areas of noncompliance within your practice are identified. Additionally, it’s important to address any lack of knowledge among your staff regarding coding mistakes and billing errors. Remember, ignorance amongst the staff doesn’t mean your practice isn’t liable for the errors.

Maldonado prefers to coach staff alone instead of in a large setting to keep the message clear. “I’ll provide one-on-one coaching with staff as well because when people start talking in groups, there can be a lot of miscommunication between people and the message can be lost,” she said.

To ensure smooth operations and avoid potential problems, it is essential to identify issues early on, maintain compliance with regulations, and hold staff accountable for accurate coding and billing practices. “There should be someone within the practice auditing you and the other coders as well. Unless there are continuous errors on the same things we discuss over and over, it shouldn’t be a disciplinary issue,” said Maldonado.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC