What are unfair medical billing practices? (2024)

What are unfair medical billing practices?

Some examples of unethical medical billing practices include upcoding (adding extra billing codes to claims), duplicate charges (billing for the same procedure multiple times), phantom charges (billing for services not performed or needed), unbundling (separating charges that should be billed together), incorrect ...

Improper payments represent payments that do not meet program requirements. The vast majority of improper payments occur in situations where there was an unintentional payment error or a reviewer cannot determine if a payment was proper due to insufficient payment documentation from a state, or a provider.

The golden rule of healthcare billing and coding departments is, “Do not code it or bill for it if it's not documented in the medical record.” Providers use clinical documentation to justify reimbursem*nts to payers when a conflict with a claim arises.

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid. program, or in reimbursem*nt for services that are not medically necessary or that. fail to meet professionally recognized standards for health care.”[

7. Billing for Non-Allowable Costs. Certain costs are considered non-allowable (or “unallowable”) under CMS's program billing guidelines. Seeking reimbursem*nt for things like private-duty personnel, training expenses, certain meals, and employee travel can also lead to enforcement proceedings under the FCA.

Unethical medical billing practices refer to fraudulent or deceptive actions taken by healthcare providers in the billing process, resulting in inappropriate charges, overbilling, or false claims. These practices can lead to financial losses for payers and can negatively impact patients.

So the Double Platinum rule is (you guessed it), “treat others the way they don't even know they want to be treated”. To boil it down… anticipate, anticipate, anticipate. Don't just meet your customer's expectations, EXCEED them.

You may be more comfortable in medical coding. Coders more often do their day-to-day work on their own in occasional collaboration with other healthcare staff. This is typically a better option for analytical, detail-oriented students uneasy with the idea of talking to people all day.

While this sentiment isn't wrong, the platinum rule says that we should treat people the way they want to be treated. This means that based on people's unique backgrounds, people should tailor their behavior toward each individual.

What is phantom billing?

Phantom billing: Billing for a service visit or supplies the patient never received. Unbundling: Submitting multiple bills for the same service.

Dirty Claim: The term dirty claim refers to the “claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment”.

Medical billing errors are a substantial issue in the US healthcare system, costing an estimated $935 million weekly. Studies indicate that around 80% of medical bills have errors, with over 25% of these mistakes due to typos.

Immediately cease filing the problematic bills. Seek knowledgeable legal counsel. Determine what money you collected in error from your patients and from the Federal health care programs and report and return overpayments. Unwind the problematic investment.

For example, physicians may have direct involvement with a durable medical equipment supplier that is a designated health service. If the physician refers durable medical equipment to a durable medical equipment supplier that they partially own, that could be a Stark law violation.

Federal False Claims Act Violations – The federal False Claims Act (FCA) makes it illegal to knowingly submit false or fraudulent claims to the federal government for payment, and it has become one of the government's most powerful tools in combatting fraud and punishing providers.

Integrity, respect, commitment, competence, fairness and responsibility are all ethical principles of professional conduct as defined by the American Academy of Professional Coders (AAPC).

Incorrect billing practices directly impact the financial health of medical practices and healthcare facilities. Denied claims, coupled with potential legal consequences for fraudulent billing, result in substantial financial losses.

Something can be unethical but perfectly legal. For example: if the emergency room is constantly backlogged, it's not legally required for the healthcare facility or hospital administrators to speed up their work.

Why is medical billing so complicated?

That's because medical billing systems are primarily set up to facilitate payment from insurance companies and government programs such as Medicare and Medicaid. These payers require bills to be submitted and formatted using specific diagnosis, treatment and supply codes or the bills won't get paid.

Payer rejection percentage = The number of claims rejected / Total number of claims. The rejection rate benchmark is less than 2%. The claims can also be rejected from the clearinghouse, but the payer rejection percentage is typically the more meaningful KPI.

In the "diamond rule", you treat others as they wish YOU to treat them. The "you" in this case is the individual "you". Who you are and what you bring to the conversation. In contrast, the platinum rule would have us all treat the person we're interacting with the same way that everyone else does.

silver rule (plural silver rules) (ethics) The principle that one should not treat other people in the manner in which one would not want to be treated by them.

The Titanium Rule: The Titanium Rule builds upon the Platinum Rule and encourages us to go beyond treating others the way they want to be treated. It suggests that we should treat others even better than they expect or anticipate, going the extra mile to demonstrate kindness, empathy, and understanding.