Healthcare Medical Insurance Processing Discussion Topic: Billing Audit Scenario

Question

Healthcare Medical Insurance Processing Discussion Topic: Billing Audit Scenario

You are a lead certified billing specialist working for a large successful internal medicine practice. The practice is comprised of 10 physicians, three (3) nurse practitioners (NP), five (5) medical assistants and four (4) billing and coding specialists (including you). Your office manager has asked you to assist her with the recent Medicare RAC audit that is being conducted on 75 random charts. During your review of the documentation and claims that were submitted, you discover that two (2) of your veteran physicians and one (1) nurse practitioner have been billing for services that were not rendered and or upcoding visits totaling approximately $250,000. What will you do upon discovering this?

Explanation / Answer

Upcoding, unbundling, and double-billing are three distinct forms of Medicare and Medicaid fraud. Generally up coding is the practice of using a billing code that results in a higher reimbursement rate than the level of service justifies. According to the given situation both the 3 physicians and nurse combindly upcoded and shown a bill for an hour long complex visits and the visits totaling worth is approximately $250,000. It is a big amount

So at first you should go through the normal channels of reporting errors in billing, beginning with the billing department and Chief Financial Officer. After this reporting you should inform the fraud investigation bureau of your state. In this fraud the physicians are also involved, so you should also alert your state’s medical board.

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