Physicians running a healthcare practice wear multiple hats, as both a business owner and a healthcare provider. In addition to providing excellent patient care, having a knowledgeable billing staff is vital. They communicate with insurance companies and patients to ensure monies are coming in to keep your practice open.
However, there are certain billing practices that can lead auditors and government agencies to your front door. Investigations, fines and criminal charges can ruin your practice’s reputation and put you at risk of losing your professional license.
ICD-10
There are over 74,000 ICD-10 diagnosis codes and 87,000 ICD-10 procedure codes. Medical billers use these codes when submitting bills to insurance companies and other payers. Payment to the healthcare provider is based on those ICD-10 codes. Upcoding is the illegal practice of billing for a more expensive procedure than what was provided.
ICD-10 codes could be misused for unbundling. Some services are grouped together under a single code. A fraudulent billing practice involves separating the services to increase reimbursement.
Duplicate billing occurs when the payer is billed several times for the same service. This is often done unintentionally. Still, it could trigger an audit of your business.
Healthcare fraud is investigated by the FBI and the Health and Human Services Office of Inspector General (HHS OIG). The consequences for problematic billing practices are severe.
The Civil Monetary Penalties Law allows the OIG to seek penalties up to $50,000 per violation. This could end up costing a healthcare practice millions of dollars.
A physician could also face imprisonment, loss of their medical licensure and, depending on resident status, deportation.
Implementing a robust compliance program can help reduce billing errors. If you’re worried about possible fraudulent billing practices, consider seeking legal guidance.