How Can Healthcare Professionals Prevent Medical Fraud and Abuse?

Healthcare

Healthcare providers can face dire consequences without processes in place to detect and prevent fraudulent activities. They may have to face an investigation that may cost them their reputation and revenue.

Medical frauds affect physicians, patients, and everyone else involved in the delivery of care. While some people think that such fraudulent activities only affect patients financially.

For instance, medical identity theft, in many cases, causes the victims’ EHRs to become corrupt. But, medical frauds negatively impact the entire healthcare industry.  Medical practitioners can also face legal troubles including federal penalties, heavy fines and even imprisonment.

As the majority of healthcare providers have shifted towards telehealth, the chances of such medical frauds have been increased. In October 2020, over 300 people were charged for committing over $6 billion in medical fraud.

As per details, healthcare providers including administrators, doctors and nurses found guilty of filing fraudulent claims to insurance companies. The major frauds were associated with telemedicine, which witnesses a surge due to the ongoing pandemic.

However, the issues of fraudulent billing have become a major challenge for healthcare providers. But, developing appropriate healthcare fraud and abuse prevention policies can save your practice.

Identifying Health Insurance Fraud

Here are the most common types of billing frauds that can land you in critical financial as well as legal roubles.

  • Unnecessary medical surgeries or treatments for the sake of maxim revenue.
  • Accepting kickbacks for patient referrals.
  • Falsifying of tests to justify unnecessary medical actions.
  • Submission of medical claims describing services that were not rendered.
  • Upcoding: It occurs as a result of using medical codes for more expensive healthcare services or procedures than were actually performed.
  • Unbundling: Which is the act of using multiple CPT codes for an individual procedure.
  • Misrepresenting non-covered treatments.
  • Charging the co-pays and deductibles to the insurer or benefit plans.
  • Billing a patient for more than their actual copay or deductible amount.

It’s a fact that healthcare providers find it challenging to comply with the myriad of regulations. Because they are already doing multiple tasks such as: patients’ care, payer compliance, medical billing, and revenue cycle management.

But  with the implementation of innovative solutions, you can stay compliant with the regulatory changes.

Best Practices to Avoid Medical Abuse and Fraud

As the healthcare industry is growing more complex, cyber crimes and medical frauds are rising. Therefore, medical practitioners must adopt the following strategies to avoid fraud and malpractice.

1. Understand the Health Care Laws and Regulations

No matter whether you prefer to in-house or outsource medical billing and coding services,  you must have an understanding of healthcare laws. You need to have in-depth knowledge of the False Claims Act (FCA).

That prohibits healthcare providers from submitting medical claims containing lower or overpriced services.

Moreover, medical practitioners should keep in mind that they can permanently lose compensation from federal insurance agencies, Medicare and Medicaid.  The federal government may fine offenders up to three times the disbursements plus $11,000 for each false claim. So, in order to prevent medical fraud, healthcare providers must ensure compliance with all federal regulations and laws.

2. Ensure Accurate Coding 

Medical coding is the lifeblood of your healthcare facility. Mostly coding errors i.e. unbundling, upcoding, over-coding leads to frauds and medical abuse.

Therefore, you should acquire the assistance of certified and well-experienced coders. Because your coding staff is responsible to translate the patients’ diagnosis and medical treatments into standards codes.

However, highly trained medical coders ensure accurate coding while maintaining strict compliance with CMS and NCCI guidelines.

Additionally, it’s imperative to continue training for your teams since medical billing and coding are ever-evolving fields. This will help them stay up to date on the latest and most specific codes to use. And it will also lower your denial rate.

However, if you can’t manage the coding and billing process at your hospital premises, then you should outsource these tasks. Offshore billers and coders are trained to identify non-compliance and fraud.

They have sound knowledge in detecting ambiguous or suspicious documentation that could lead to fraud. Moreover, in order to avoid inadvertent fraud, they maintain accurate billing practices to avoid overcharges, etc.

3. Maintain Proper Medical Documentation

Sometimes the problem starts with the front desk information. If your registration staff doesn’t capture patients’ demographic information carefully then the chances of billing errors increases. In addition to this, the information in medical records should be documented on a daily basis 

Therefore, healthcare providers should train their front-end staff to maintain accurate medical records. Which also helps medical practitioners in defending themselves against malpractice suits.

Moreover, in order to increase the efficiency of the patient’s records, you should stop using manual methods to process data. Implementation of Electronic Healthcare Records (EHR) prevents errors.

The exchange of health information electronically can help you to ensure accuracy in the entire medical billing and coding process.

Medical Billing Benefits keeps you updated with the latest healthcare trends in the United States. Stay tuned to know more about the current evolutions in the medical industry.

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