Medical Billing and Coding Healthcare Blog

May 16, 2011 - There are many different kinds of Medicare fraud yet the goal is always the same – to rook money from the Medicare program. Generally Medicare fraud is challenging to track as not all fraud is detected and not all suspicious claims prove to be fraudulent. That is when Medicare abuse is in place. It occurs when physicians or suppliers fail to follow best medical practices, resulting in unnecessary costs to Medicare such as improper payments, or medically irrelevant services. In fact, Medicare fraud – estimated now to total about $60 billion a year – has become one of, if not the most profitable, crimes in America..

Significant decrease of fraud will cut costs for families, businesses and the federal government. Instead it will increase the quality of services for those in need of care. The U.S. Department of Health and Human Services (HHS) and U.S. Department of Justice are proactively cooperating to help eliminate fraud and investigate fraudulent Medicare (and Medicaid) operators who are cheating the system.

On January 24, 2011, HHS announced new rules authorized under the Affordable Care Act that will help prevent defrauding the Medicare program. These rules serve to protect patients and legitimate doctors as well as other providers. They include: enhanced screening and other enrollment requirements (rigorous screening process for providers enrolling Medicare in order to keep fraudulent providers out of the program), stopping payment of suspect claims (the program can temporarily stop enrollment of a category of providers or of providers within a geographic area that has been identified as high risk), new resources and sharing data to fight fraud, new tools to prevent fraud, expanded overpayment recovery efforts, enhanced penalties to deter fraud and abuse, stiff new rules and sentences for criminals, greater oversight of private insurance abuses.

According to federal law, a healthcare provider filing a false claim for medical services that not provided, weren’t rendered in full, or that were medically unnecessary, can be subjected to 5 years of prison, a $250,000 fine as an individual and $500,000 for a corporation, or both. In case of making false statements, or covering up material, offenders will pay a $10,000 fine, and serve a 5 years prison sentence, or both. Soliciting monies or services, or receiving them, in exchange for gifts, financial rewards, or services that Medicare covers, is also a crime. Penalties for this could include a fine of $25,000 and/or serve 5 years in prison. If a prosecutor can prove that the violator used certain forms of media (TV, Internet etc.) to advance such deceit to the public, they can end up in jail for 5 years, plus become liable to pay a $1,000 fine. Finally, according to the recent passage of the Kennedy-Kasselbaum Act, if the offender schemes to defraud any healthcare agency, they may draw penalties of up to 10 years of imprisonment, plus any court costs, fines, or financial penalties the court deems fit to assign them. If an injury occurs due to such schemes, the sentence may get up to 20 years plus fines. In case of death the penalty may turn into a life term in prison.

Physicians can take 2 simple steps to avoid accusation of Medicare fraud or abuse in the future: billing audits and keeping detailed and accurate patient records. Conducting regular audits may disclose contradictions that should be investigated and corrected immediately. Detailed and accurate records will assist any investigator in determining whether a medical billing issue was fraud or a mistake, and will help eliminate any mismatch quickly. Ultimately, the easiest way to elude prosecution of healthcare fraud is keep up with the relevant laws, regulate your billing practices, and immediately deal with errors discovered during routine audits.

June 7, 2012 - There was never any doubt that the healthcare industry would grow exponentially, but few people realized 15 or even 10 years ago how dramatic the changes were going to be. The American population has grown older at the same time medical technology has advanced. Treatments thought nearly impossible are now everyday occurrences. The demand for these new treatments combined with the growing number of elderly patients has placed its own unique strains on medical billing systems. These changes have resulted in the need for new a system of medical coding and it is the ICD – 10 codes that will be responding to the challenge.

The International Statistical Classification of Diseases and Related Health Problems, or ICD codes, are used to classify not only diseases but also a wide range of symptoms and procedures of healthcare. It is the basis for medical billing and the ICD – 9 has been the workhorse code for years. However, due to the advances in medical treatment and technology, not to mention legislative changes, there are more situations than the ICD – 9 codes can fully cover. The ICD – 10 code terminology has been in existence since the 1990s but was slow to be accepted by the healthcare industry in the United States. That is now about to change.

The United States Department of Health and Human Services is about to require that those healthcare entities that deal with the Health Insurance Portability and Accountability Act of 1996 (HIPPA) use the ICD – 10 in place of the older ICD – 9. There has been a recent delay announced of compliance until October 1, 2014 to allow for additional review, but unless something dramatic is uncovered it is likely that the ICD – 10 codes will be universally used in American healthcare. This will bring about a major change in the field of medical billing and records. The ICD – 10 code sets have over 150,000 different codes as opposed to the approximately 17,000 codes found in ICD – 9. The ICD – 10 takes into account the advances in medicine, treatment, and diagnosis that occurred in the past few decades. Moreover, the ICD – 10 has already been adopted by a number of countries, including Germany, France and Australia. It is most likely that more and more countries will adopt the ICD-10 codes in the coming years.

This new code will bring about sizable changes in how billing and recordkeeping are done. Career minded medical coders will have to become proficient in ICD – 10 code terminology and software, and medical billing and records keeping will have to be revised to reflect the ICD – 10 lexicon of terms and codes. This all may prove to be extremely expensive as the transition to the new codes runs its course. The possibility of some confusion and administrative difficulty is quite real, as this happens in the event of any major change. It does mean that institutions training medical coders will have to offer increasingly more courses in ICD – 10 and discard the ICD – 9 curriculums. Nevertheless, there is a sizable benefit to be derived from the new codes, including more precise labeling of treatments and symptoms among other things. The ICD – 10 codes will eventually make the pricing of various healthcare services easier and more accurate.

This article was provided by our friends at the Medical Coding Training & Certification Guide – a free resource for current and aspiring medical coders. From general industry information, to specific job opportunities, all the important aspects of the medical coding profession are covered.