Small medical businesses ranging from hospices to in-home physical therapy providers have many liabilities to address. There are state licensing and insurance matters to consider, as well as industry regulations and care standards that may influence how the company operates.
The need to generate adequate revenue can also influence how a business operates. Little billing tricks can sometimes help companies increase the revenue that they generate by providing patient services. However, those clever billing tactics can endanger the business, especially if the organization works with clients who have Medicare or Medicaid coverage.
Any of the three billing practices outlined below could potentially lead to an investigation into a company’s practices and health care fraud allegations against billing professionals, healthcare providers or business owners.
Upcoding
Upcoding has become one of the most notorious forms of health care fraud. Upcoding involves changing the billing code submitted to the insurance. The patient does receive some type of service, but the provider bills for more expensive services than the ones the patient actually received. Signs of upcoding can lead to intense scrutiny of the company’s billing practices for not just that patient but many others.
Unbundling
Another way for healthcare providers to optimize revenue for services provided is to bill separately for services often discounted when billed as bundled services. Typically, health care providers accept bundle-based discounts as part of their contracts with different insurance programs. Intentionally separating those discounted services to bill for more money can lead to fraud investigations and possibly criminal charges.
Billing for missed appointments
Many physician’s offices and other health care specialists impose financial penalties for missed appointments. They charge patients who cancel their appointments without advance notice specifically because those cancellations cost the company money. A healthcare provider cannot schedule someone else for that appointment time and cannot bill insurance for services they did not provide. Sometimes, frustrated health care providers or their support staff may decide to submit a claim to insurance for a canceled or missed appointment even though the healthcare provider did not actually see or treat the patient in question.
Anytime that regulatory officials suspect a medical business of billing for services they didn’t provide or overcharging insurance companies, an in-depth investigation could possibly occur. A health care fraud investigation might lead to criminal charges, orders of restitution and licensing complications for medical professionals. Getting assistance as soon as there are signs of a fraud investigation can help those who work in the medical sector avoid worst-case scenarios.