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5 Common Fraudulent Coding, Billing Schemes

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The number of disreputable healthcare providers trying to scam the system is increasing, and knowing where schemes tend to appear is the first defense in fighting fraud, according to Healthcare Finance News.

Here are five common coding and billing schemes used to perpetrate fraud.

1. Upcoding. The most common form of fraud is medical providers billing for a more complex procedure than was actually performed. Unless a physician clearly documents a comprehensive history and physician exam, a severe medical program or 45 to 60 face-to-face minutes with a patient, charges for these upcoded visits should be rejected.

2. Unbundling. Unbundling occurs when a provider bills separately for components in a bundled package. When individual supplies and services are charged separately, the cost can be significantly higher.

3. Kitchen sink coding. Though technically only confirmed diagnoses can be coded, physicians often throw in other codes, called kitchen sink coding. Providers may have a poor understanding of coding guidelines or may be justifying various treatments or exaggerating injures. This practice can hurt patients in the long-run by creating preexisting conditions they may never actually have had.

4. Inconsistent coding. Inconsistent coding often means a patient's diagnosis changes without a change in his symptoms, particularly right before surgery. It can also occur when procedures listed on the physician's bill do not match procedures on the hospital or surgery center's bill.

5. Inflated charges. When medical bills are not first submitted to an insurance provider for payment, physicians can simply inflate charges. This often occurs for persona injury cases. All states require accident victim's medical bills be usual, customary and reasonable, but few have actually defined was UCR means.

More Articles on Coding, Billing and Collections:
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What Does the Medicare 2013 Payment Rule Mean for ASCs? ASCA Weighs In
10 Key Steps to Managed Care Contracting


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