Provider Alert: How A Medical Claim Dispute Could Change into Medical Billing Fraud

by | Published on Mar 19, 2018 | Medical Review Services

Can a medical claim or billing dispute develop into a medical billing fraud case? It could, going by Bloomberg Law reports. Typically, medical records review and medical claim review are processes health insurers use to determine the validity of provider claims. Health lawyers say that they are seeing increased number of civil actions based on health insurer fraud investigations. When these investigation units are involved, there is the risk of those cases being referred to law enforcement for criminal fraud prosecutions. Now, healthcare providers have to focus more on ensuring that they comply with claim coding, claim submission and other requirements to avoid a billing oversight lapse turning into a criminal fraud prosecution.

How can such a prosecution procedure develop? Such proceedings could develop through the HFPP (Healthcare Fraud Prevention Partnership), which is a voluntary public-private partnership that aims to share information about potential fraud. Most major private payers such as Anthem, Aetna, Cigna, Humana, United Healthcare, Molina, Moda, Centene, and many of the Blue Cross Blue Shield affiliates are partners in this agency along with the FBI, the U.S. Department of Justice, the U.S. Department of Health and Human Services, and Medicaid agencies in 17 U.S. states.

The first step in this entire process is claims auditing undertaken by payers to verify whether healthcare providers are properly coding and documenting their medical claims submitted for reimbursement. Auditing involves comprehensive medical claims review that helps determine the medical necessity, appropriateness, and efficiency of the medical services provided. Attorneys who responded to Bloomberg Law pointed out that with the reality of increasing healthcare expenses, carriers are carrying out more aggressive audits of medical claims. Therefore, physicians and other healthcare providers have to be very careful about their medical billing and coding. A detailed review of claims before submission could help ensure accuracy and compliance. If an insurer’s SIU (Special Investigation Unit) gets involved, it is a major concern for providers because they tend to be more forceful, and billing disputes could end up as civil fraud claims. Attorneys representing healthcare providers are more worried about insurers using audits and their SIUs to alter the focus of billing disputes and allege fraud. They feel that payers could work with providers to resolve discrepancies and other concerns. Health plans concede that they work alongside state and federal law enforcement but do so only when signs of healthcare fraud are detected.

When a fraud claim is brought in, do law enforcement officers take them at face value? No, according to Melissa L. Jampol, a former federal prosecutor who now represents healthcare providers. Federal prosecutors would not simply accept a “ready-packaged” case. They would consider the entity who has complained about potential fraud, including complaints to payers and use those complaints along with any related SIU investigation to determine the genuineness of the allegation.

If fraud is suspected, it could lead to criminal charges under 18 U.S.C. § 1347-a federal health-care fraud statute that was added in 1996 as part of the Health Insurance Portability and Accountability Act (HIPAA)-or under the Anti-Kickback Statute or related federal criminal statutes involving conspiracy, wire fraud, and mail fraud.

Providers must take insurer audits seriously and respond as required. They must ensure that the payer’s requests for additional documentation are handled promptly by staff members who clearly understand the concerns of the investigators. They should try and communicate directly with the investigators from the beginning itself. Attorneys say that audits become more challenging when the claim volume is huge. The problem, they say, is a hospital for instance, could process hundreds of similar claims before they receive notice of a claim denial. The challenge is in keeping track of all denials and still processing a huge volume of claims that may be erroneous. The recommendations are that providers,

  • Should not ignore private payers, and must treat their interactions with commercial payers in the same way they would treat those with Medicare or Medicaid auditors.
  • Must look at their high-volume, high-dollar private payer claims too and ensure they are properly ordered, documented, and coded.
  • Must have a strong compliance program that will reduce exposure. This will help show that they are acting in good faith.

All this highlights the fact that providing superior quality medical care may not be enough to survive a payer audit. Utilizing expert medical claim review service, providers can ensure their claims are accurate and meet all compliance requirements of government as well as private payers.

Discover our medical record review solutions and partner with us for your next case.

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