Many cases of billing fraud are egregious and hard to ignore. A coding professional upcodes a procedure to charge more money. A billing specialist might enter multiple separate billing codes for procedures that are eligible for a discounted billing arrangement.
The motive in such cases is almost always to optimize the company’s profitability, often at the expense of the insurance company or government insurance program. Occasionally, compliance issues with insurance billing rules come from a place of kindness and compassion rather than greed.
Employees working for a busy medical practice might try to submit a billing request for a canceled or missed appointment. They may do so as a courtesy to the patient, not realizing that it could put the organization at risk of compliance issues and leave them exposed to allegations of insurance billing fraud.
Cancellation fees are costly
Tight scheduling is a common practice at most medical offices. There is limited time in between appointments, in part to help optimize the revenue generated by the business. When a patient misses their appointment or cancels with limited advance notice, the practice may assess a hefty no-show fee.
Many medical offices now require 24-hour advance notice of cancellation and may charge $100 or more for a missed appointment. Patients may struggle to come up with those funds and may not be able to schedule a new appointment until they pay the fee. Particularly when the patient is an older adult who relies on Medicare or a low-income patient who uses Medicaid benefits, the cancellation fee could become an insurmountable financial obstacle.
The professionals providing assistance at a medical office may agree to submit a billing claim to insurance on behalf of a patient who wants to avoid a no-show fee. Unfortunately, this is an actionable form of billing fraud, sometimes referred to as phantom billing. While the intention may have been to protect a patient from financial hardship, the outcome is that an insurance provider or government benefits program has to pay for an appointment that did not actually occur.
Especially in scenarios where billing for canceled appointments becomes common practice, the business might be at risk of compliance issues. Providing appropriate training to those directly interacting with patients, as well as billing and coding specialists, can help prevent scenarios in which a medical business is at risk of legal controversy because of billing practices.
Proactively preventing billing compliance issues is important, as is knowing how to respond when there are questions about the organization’s billing habits. Securing representation when establishing a medical business, navigating compliance issues and responding to allegations of misconduct can help those who own or run medical businesses limit their exposure.