Physician Overbilling and UpcodingAccording to a new report by ProPublica, despite increased focus on the cost of healthcare and scrutiny by federal regulators, problems with physician overcoding and overbilling persists. Several reports have already proven that accurate medical billing and coding services play a critical role in better healthcare reimbursement. Based on the analysis of CMS data from 2012 to 2015 on services provided by and payments made to providers under Medicare’s Part B program in 2015, the report proves that the current condition has changed little from 2012 to 2015.

The team analyzed provider billing patterns for standard office visits in Medicare and found that

  • More than 490,000 providers billed the CMS for standard office visits for at least 11 patients in 2015
  • Of those, more than 1,250 providers billed for every office visit using the 99215 code, which is only to be used for visits that involve a comprehensive examination and often consumes more time
  • Additionally, 1,825 health professionals billed Medicare for the highest level type of office visit for established patients almost 90 percent of the time in 2015

Fraudulent billing practices that are getting more common include billing for services not provided, upcoding or billing for a more expensive service than what was actually provided, billing for services the patient did not need, falsifying a patient’s medical record to justify tests or procedures that are not medically necessary or billing for durable medical equipment that was never given to the patient.

Suggested solutions to fix problems

  • Transition from clinician payment based on relative value units (RVUs) to value based care would go a long way in addressing overbilling
  • Advising providers to make better use of EHR, as they can document better with the use of an EHR and the EHR can also suggest the level of service to bill using the documentation
  • Physician Overbilling and OvercodingHiring certified coders and qualified staff or opting for medical billing and coding outsourcing to handle a provider’s billing procedures, which includes overseeing coding, billing and collection activities. Experienced billing professionals stay current on regulatory requirements and all coding, compliance and pay or regulations.
  • Practices must take control and ownership of how they are documenting their services and portraying their patients to the payers. They should understand how to document thoroughly and bill appropriately using the correct codes for the services provided.

Violating federal laws may result in non-payment of claims, Civil Monetary Penalties (CMPs), exclusion from all Federal health care programs (including Medicare), and criminal and civil liability.

Several educational resources and programs are available online to help physicians avoid Medicare fraud and abuse. CMS has published a booklet – “Avoiding Medicare Fraud & Abuse: A Road map for Physicians”, which helps physicians understand how to comply with these Federal laws by identifying “red flags” that could lead to potential liability in criminal, civil, and administrative enforcement actions. While choosing a medical billing company, physicians must make sure that the firm is experienced and is well aware of such Federal programs and coding standards.