Monday, January 30, 2023

How To Recognize Industry Scams In Medical Billing And Coding

Must read

Many work opportunities exist in the booming medical billing and coding sector today. Unfortunately, more people are seeking to take advantage of eager trainees as more job openings and training programs are available. Industry Scams are widespread in the realm of medical coding and billing, and they commonly target newcomers to the industry. How can you tell what is a legitimate application and what is a scam if you don’t have any experience with coding and billing? We’ll assist you in determining that during this article.

Most industry scams claim they can get you certified in billing or coding in less than a month. You can learn at home! You can conduct business from home! You can get a job in a few weeks if you only take these ten classes.

Would it be that simple?

Learning medical billing and coding takes a lot of practice. It should take you at least six months to a year to complete your training in coding and billing, and most associate’s degree programs last two years. It would take too long to become proficient in the coding and billing fields in a single month.

There is no way you could study everything there is to know about anatomy and physiology, ICD-10-CM codes, CPT codes, billing guidelines, payer structures, HCPCS compliance, etc., even with 36 hours in a day.

Your first indicator of a billing and coding program’s quality should be how long it lasts. Avoid the entire thing if you see anything guaranteeing a certification or program completion in less than six months.

Work from Home

Another popular selling element of billing and coding fraud is the opportunity to work from home. Perhaps you’re a stay-at-home parent, or you like the concept of having a home office. The “create your own billing/coding business” con is another variation.

Numerous programs include software, educational materials, and a network of business connections looking for assistance with billing and coding.

Consider this: Coders and billers manage a lot of sensitive private information, including social security numbers and patient medical histories, and are crucial to the reimbursement process for healthcare. Do you suppose a supplier would give that information to a potential customer who has no prior industry experience and, consequently, no professional references?

The individuals who manage billing and coding businesses out of their homes sometimes have years of expertise, if not more than a decade.

You must demonstrate that you are familiar with every aspect of the business, as no employer will consider hiring a fresh coder without any prior experience in billing or coding. If you want to begin working as a medical coder, you will do so in a doctor’s office.

The gist: Steer clear of any programs that promise you’ll be able to work from home or launch your own company.

Other means of seeing a scam

You should probably avoid a service that offers coding and billing education if it isn’t accredited by or connected to critical trade organizations, such as the American Association of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).

Accreditation ensures the caliber of instruction at an educational institution. Remember that although for-profit online institutions (like the University of Phoenix) are accredited, that doesn’t necessarily make them better choices for studying coding and billing. Private for-profit colleges, like many Industry Scams, promise coding proficiency in just a few months, even though, as we all know, being fully fluent in billing and coding might take more than a year.

Associations for health information professionals (including AAPC and AHIMA) are interested in combating coding and billing fraud.

It is not worthwhile to pay for classes from a coding and billing school if it is not endorsed or acknowledged by one of these influential professional organizations.

Finally, it would be best if you inquired about the reputation of a dubious billing and coding company with the Better Business Bureau. There is a good chance that a billing or coding instruction service will be the subject of complaints if it is a fraud. If you study well, you can recognize a scam immediately.

Typical Medical Billing Fraud Types

  • Upcoding

When a code is allocated for a condition that is more severe than the patient’s actual health, this is known as upcoding. Because insurers will pay more for the more serious diagnostic code, it should theoretically enable a practice to gain revenue. The Office of Inspector General maintains a list of principles that are candidates for upcoding and may inspect an approach that files claims that seem dubious. The procedure could face a hefty fine if the audit reveals errors.

  • Insufficient documentation

Because many different types of claims are filed to an insurer without medical documents, false records can be challenging to spot, especially when done accidentally. This enables providers familiar with insurer procedures to increase reimbursements without triggering an audit, even though they are aware that changing medical records to improve the claim, purposefully omitting crucial information, and changing the claim’s code to increase reimbursement are all against the law.

  • Overly generous patient services

Charges for treatments not rendered during a visit and redundant services are examples of medical fraud frequently committed by charging insurance for more benefits than the patient required. If intentional charges arise due to generally inadequate billing procedures, it may be challenging to identify them. Unfortunately, this is not always the case. Health care practices should have policies that can record each service’s fee.

  • Billing for Non-Covered Services

One illustration is when a doctor offers a treatment that an insurance company may not have approved because it is deemed experimental. They continue to file the claim documents, after which they get reimbursed for the care. The problem is that the submitted claim refers to the experimental therapy as something else, which makes it insurance-covered. Additionally, they submitted claims for more visits than were necessary.

  • Service dates

Because each office visit is therefore seen as a different service, a medical professional may be able to charge more if they record seeing or treating the same patient twice rather than once. It would be medical billing fraud even if the procedures were legitimately performed because the dates are made up.

  • Places of Service

According to this approach, a doctor would administer a series of injections to a patient to diminish a food or airborne allergy. Then, the injections would be administered twice a week. The office might attempt to submit bills indicating that each infusion was administered at the facility when the patient administered the injections at home. Self-injection is not a cost that can be reimbursed.

  • Service Provider

Unsettling but valid Sometimes, a doctor will submit and sign a claim even though the patient was cared for by someone with less training in medicine. In these situations, the insurance companies would still pay for the service even if a less-educated therapist delivered it.

Everything that seems too good to be true in coding and billing teaching services is probably true. Any educational program guaranteeing a job, certification, or competence in less than six months should be avoided.

And it’s always wiser to err on the side of caution and only consider courses that last for at least a year. The primary industry professional bodies should accredit or recognize a coding and billing educational program.

Avoiding all shortcuts is the most excellent approach to avoiding a medical billing and coding scam. Look for certification or associate degree programs at your neighborhood community college or trade school.

FAQs on Recognizing Industry Scams

What are some effects of incorrect billing and coding in the workplace?

Your reimbursements may be refused, delayed, or partially paid due to inaccurate medical coding. If you accumulate a backlog of overdue repayments, your emergency medicine clinic will have to cope with mountains of paperwork, stress, and lost income.

Who is legally obligated to guarantee coding accuracy?

Which came first, the doctor or the coder? Legally, a doctor, physician assistant, or nurse practitioner enrolls in Medicare, Medicaid, or commercial insurance and forms a declaration promising to submit correct claims.

Why is accurate coding crucial?

Correct coding and documentation will result in more actual payments, avoid payment denials, and minimize payment delays. With the help of coded data, Signature’s coding accuracy improves clinical, financial, and administrative planning for performance monitoring.

What moral concerns exist with clinical coding?

Clinical Coding Ethics and Legal Requirements

Respect privacy, secrecy, disclosure, and security laws and regulations governing patient-related information privacy. Refuse to participate in or cover up unethical or unlawful processes or practices.


” width=”20″ height=”20″>

More articles

I am a medical biller, a blogger and have 20 years of experience in medical billing, medical billing management, and medical assistant. My background includes positions as a clinical medical assistant, medical records technician, medical office manager, biller, and coder. I am certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) and by the Practice Management Institute (PMI) as a Certified Medical Office Manager (CMOM). As an office manager/biller/coder, I was a member of the Michigan Medical Group Managers, Michigan Medical Billers Association. I also served as a committee member of the Michigan Osteopathic Association of Practice Managers Education Committee.

Latest article