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7 Most Common Risks Related to Medical Billing & Coding

January 15, 2015

medical billingMedical billing is a complicated process, and getting through the process smoothly requires an awareness of the risks involved. Making a mistake when it comes to medical billing and coding can cost your office a lot of money and headaches. Not to mention, it can destroy your relationship with your client. Luckily, if you know where the pitfalls are, you can avoid the common mistakes made by others. Here are 7 risks related to medical billing and coding that you always need to be aware of:

1. Billing for Services Not Rendered

Sometimes the provider will add tests, treatments, or procedures to the bill that were never performed on the patient. The big risk here is that these can go unnoticed when they are added to tests, treatments, or procedures that actually were performed or received by the patient. A provider may also add on unnecessary tests or services by falsifying a diagnosis.

2. Duplicate or Wrongful Billing

Just like it sounds, duplicate billing happens when a provider bills for the same procedure, test, or treatment multiple times. A fraud investigation can ensue if a provider continuously submits duplicate bills and is considered an abusive biller.

3. Upcoding or Unbundling

Upcoding refers to when a provider misrepresents the level of service or procedure performed in order to charge more money or receive a higher reimbursement rate. Upcoding also happens in cases when a service is not covered by Medicare and the provider bills a covered service in its place. Unbundling refers to the process of separately billing for procedures that are normally billed together. 

4. Inappropriate E&M Coding

Evaluation and Management (E&M) coding for diagnosis and treatments need to be accurate for reimbursement purposes and to meet coding compliance guidelines. The wrong codes will affect the reimbursement procedure because the payer will not have accurate information regarding the patient’s illness or injury or the treatment plan in place.

5. Coding Without Appropriate Medical Documentation

Including the appropriate documentation along with coding is essential for receiving accurate and prompt reimbursement. Official office medical forms, letterheads, and/or invoices should include appropriate authoritative signatures if necessary.

6. Unlawful Collection Practices

In a time when many medical practices are becoming more and more aggressive in receiving payments from patients, it is important to know and understand the laws regarding payment collections. For instance, you must provide an appropriate amount of time for patients to make payments before sending their bills to a collections agency. Know the rules and regulations make sure everyone in your office is aware of them in order to avoid legal issues down the road.

7. Failure to Enforce Internal Controls

Internal controls refer to a process designed to discourage fraud, safeguard company resources, and ensure compliance with laws and regulations.  Separating duties is an important and effective way to make sure that money is not lost due to a front desk error or an administrative mistake. Employees who understand that each step of the process is monitored and double-checked are more likely to take steps to ensure accuracy throughout the billing process.

We know that medical billing is a complex process, and committing one or several of the above mistakes can be costly for your office and potentially land you in legal trouble. Working with a professional medical billing office that can handle all of your billing, coding, and documentation will simplify the medical billing and coding process as well as ensure accuracy. Contact us today to see how we can help your office simplify the medical billing and coding process.


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