Diligence in claim filing can reduce medical audit anxiety

Who doesn't like taking shortcuts. If there is a way to get from point A to point B more easily, that's a good thing, right? That might be true in on the road, but in the health care industry, taking shortcuts around regulatory obligations can lead to financial trouble. Worse, it can result in criminal charges and result in penalties that derail careers.

Few medical practitioners intentionally follow practices that trigger investigations. However, those entities that pay claims know errors happen either by accident or on purpose, and they don't have any desire to be left holding the bag if mistakes lead to overpayments. Audits are possible and those with experience in health care law know they need to be taken seriously.

Even industry veterans need to be aware

Few outside the industry have an appreciation for how complicated claims processes can be, or how much anxiety can be generated when a payer, whether it is a commercial insurer, or Medicare or Medicaid regulators, reveals that an investigation is underway for billing fraud and abuse. One of the key triggers for such probes is suspected billing fraud and abuse caused by incorrect coding. And, obviously, the best way to reduce risk of unwanted action is through the exercise of solid due diligence.

Perhaps no agency is more attuned to the issues that signal claims problems than the Office of the Inspector General at the federal Department of Health and Human Services, so it should be no surprise that it recently issued a training publication for medical practices. The target audience is new doctors, but the American Medical Association says it's useful for all in the field.

The document highlights several common missteps to avoid. They include:

  • Using billing codes that indicate a more severe patient condition than existed or more expensive treatment than was delivered.
  • Submitting bills for treatment never delivered at all.
  • Claiming payment for medically unnecessary services.
  • Seeking to recover for services delivered by an unqualified, unsupervised, or unauthorized employee.
  • Billing for low quality services that could be construed as being worthless.
  • Charging separately for a service included under a global fee, such as an evaluative visit following a surgical procedure.

Regulator efforts to fight abuse and fraud are here to stay and can be onerous. But health care providers are not without rights, too. If you have concerns your rights are under threat, consult an attorney

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