Professional Physician Billing Services – Avoid Allegations of Fraud

by | Last updated Jun 19, 2023 | Published on May 6, 2016 | Medical Billing

Physician Billing
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When it comes to revenue cycle management in busy medical facilities, opting for physician billing services is the feasible option. Another key benefit of choosing a reliable service provider is that it can help them avoid allegations of fraud.

Improper Medicare and Medicaid billing errors are wasting billions of tax payer dollars every year and the federal government is taking stern measures to handle the issue. The aim of the government’s Recovery Audit Program is to fight fraud, waste and abuse in the Medicare program by indentifying overpayments and underpayments for Medicare claims so that CMS can implement preventable steps in all the states. Under the program, the Centers for Medicare & Medicaid Services (CMS) hire Recovery Audit Contractors (RACs) to review medical records at short notice.

Medical Billing for Cancer Treatment in the Spotlight

Oncology medical billing is in the spotlight with Boston Medical Center coming under scrutiny for alleged improper Medicare and Medicaid billing pertaining to the expensive cancer drug Rituxan. According to the Boston Globe news report, the hospital and two of its physician groups were charged on three counts, two of which relate to oncology billing:

  • billing Medicare for more units of the cancer drug Rituxan than it actually used
  • billing Medicare and Medicaid for services at a pre-surgical center that were covered by other fees
  • submitting claims to Medicare for outpatient podiatry services that were deemed medically unnecessary

BMC has also been charged with improperly billing Medicare and Medicaid for services at its pre-surgical treatment center, though those treatments had been covered under a fee for which the hospital was already being reimbursed.

Settling the allegations of fraudulent billing of Medicare and Medicaid claims will cost BMC a whopping $1.1 million.

Medicare Billing for Rituxan (Rituximab) – Adherence to CMS Guidelines

In the HCPCS manual, J9310 is defined as: Injection, rituximab, 100 mg. It is used to treat Chronic Lymphoid Leukemia and Non-Hodgkins Lymphoma.

Billing Medicare for rituximab (J9310) can be performed correctly by adhering to the following points:

  • One (1) unit represents 100 mg of rituxima bordered/administered per patient
  • Rituximab should be billed based on units

For example, if the quantity administered is 200 mg and the description of the drug code is 100 mg, the units billed should be two (2).

Avoid Fraudulent Billing with Professional Physician Billing Services

To accurately bill for Rituxan, a professional medical billing company would ensure adherence to the practices recommended by CMS:

  • verify the milligrams given by the physician
  • convert the milligrams to the  proper  units  for  billing
  • ensure that the quantity of the drug administered is  consistent with the units billed

Such companies have AAPC-certified medical coders who are well-versed in all aspects related to billing for various specialties including oncology. They would ensure proper medical billing and coding by differentiating between unit billing versus milligram billing on this expensive cancer drug.

  • Natalie Tornese
    Natalie Tornese
    CPC: Director of Revenue Cycle Management

    Natalie joined MOS’ Revenue Cycle Management Division in October 2011. She brings twenty five years of hands on management experience to the company.

  • Meghann Drella
    Meghann Drella
    CPC: Senior Solutions Manager: Practice and RCM

    Meghann joined MOS’ Revenue Cycle Management Division in February of 2013. She is CPC certified with the American Academy of Professional Coders (AAPC).

  • Amber Darst
    Amber Darst
    Solutions Manager: Practice and RCM

    Hired for her dental expertise, Amber brings a wealth of knowledge and understanding of the dental revenue cycle management (RCM) services to MOS.

  • Loralee Kapp
    Loralee Kapp
    Solutions Manager: Practice and RCM

    Loralee joined MOS’ Revenue Cycle Management Division in October 2021. She has over five years of experience in medical coding and Health Information Management practices.