Untrained Billing Staff in Doctor's Offices May Increase Fraud Risk, Say Experts

Even unintentional fraud can lead to big fines and liability. Doctors can protect themselves and avoid medical audits by hiring certified medical coding staff.

SAN ANTONIO, Nov. 27, 2017 /PRNewswire-iReach/ -- Billions of medical claims are processed annually by private insurers and governmental agencies such as Medicare and Medicaid. Healthcare providers that submit erroneous or inaccurate claims may face allegations of fraud and may result in fines and loss of reputation and good industry standing.

"When most people think of fraud, they see it as a deliberate act of deceit. But that's not always the case," said David Womack, President and CEO of Practice Management Institute (PMI). "The vast majority of doctors are trying to make an honest living."

Womack, whose company teaches coding and reimbursement compliance for medical office staff, said that one of the easiest and most effective ways doctors can minimize their risk for fraud is by employing properly trained medical administrative staff to handle third-party claim submissions. These professionals translate the documentation provided by the physician about a patient encounter into codes that insurers use to reimburse for services rendered.

There are thousands of codes and code combinations available to represent a type of visit, diagnosis, how a procedure was performed, whether more than one procedure occurred at the same time, the extent of a patient's examination, etc. Examples of improper submissions include "upcoding" – using inappropriate billing codes to indicate that a more complex or lengthy procedure was performed, or "unbundling" of codes – using different codes for each step of a procedure even when one code assigned to encompass all steps in the procedure will do.(1)

One of the best ways to prevent fraud allegations is to hire competent, well-trained staff, said Womack.

"A well-trained staff demonstrates a good faith effort to ensure compliance with the rules and regulations of the healthcare insurance industry," said Womack. "Assigning precise codes is essential for proper reimbursement."

Healthcare providers reimbursed at rates higher than what the care they actually delivered are at risk of fraud allegations. Physicians are liable for mistakes their staff make—even if those mistakes were unintentional. There are many rules and regulations providers must follow when billing, and these rules usually change every year.(2) It can be difficult for providers to stay on top of the latest billing requirements and errors in provider compliance easily lead to medical audits and fraud investigations.

If a doctor gets hit with allegations of fraud, he or she can lose substantial amounts of money and reputation as an honest healthcare provider, even if an unskilled coder was responsible for the incorrectly coded claims.              

"Fraud and abuse defense experts that we work with tell us that advanced training in coding and billing does help safeguard physician practices, finances and reputations," said Womack. "If a physician can prove their staff has completed relevant reimbursement training and certification, it may help show good faith effort if an infringement occurs."

About Practice Management Institute (PMI):

For more than 30 years, Practice Management Institute, also known as PMI, has helped physicians, hospital systems, medical societies and educational institutions provide comprehensive education and training to medical office staff nationwide. By offering a variety of educational programs and professional certifications, PMI helps to build competency, compliancy and effectiveness, assuring the continued success of its clients.

Since PMI's formation in 1983, more than 20,000 individuals have earned certification in one more areas of expertise. PMI is recognized by both the Centers for Medicare and Medicaid Services and the Department of Labor for training in medical coding, third-party billing, office management, and compliance. PMI training helps ease the burden of running a successful medical practice through thorough education and up-to-date training for non-clinical staff, allowing physicians to focus on patient care to improve the experience of the patient. For online coding and compliance training at affordable rates, visit www.pmimd.com/onlinetraining.

About David Womack:

David Womack, president and CEO of PMI, has been instrumental in PMI's continued success since 1991. He has helped PMI transition into a cutting-edge leader in medical office staff education and training while developing key relationships with healthcare organizations, hospitals, colleges and medical societies across the country. His commitment to excellence has helped PMI become an industry leader recognized by both governmental organizations and healthcare systems across the country.

Sources:

1.    Health Care Billing Errors and Fraud. AARP. https://www.aarp.org/health/health-insurance/info-05-2012/health-care-billing-errors-and-fraud.html

2.    How Providers Can Detect, Prevent Healthcare Fraud and Abuse. RevCycle Intelligence. https://revcycleintelligence.com/features/how-providers-can-detect-prevent-healthcare-fraud-and-abuse

Media Contact: Karla Jo Helms, JoTo PR, 888-202-4614, mradmin@jotopr.com

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SOURCE Practice Managment Institute



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