Billing Audits and "Red Flags"
By Angie Gunderson
Jan 15, 2008, 21:44
From a Chiropractic Billing Consultant
Since this is the beginning of a new year, I will start with the Top 10 Red Flags for a billing audit (in no particular order):
1. “Phantom Billing”—Billing for services not rendered.
2. “Double Billing”—charging more than once for the same service, e.g., using an individual code again as part of an automated or bundled set of tests.
3. “Clustering”—Using only a few codes on the theory that it will average out.
4. “Upcoding”—Using a higher reimbursement code than the code reflecting the service rendered; e.g., billing for complex services when only simple services were performed, billing for brand named drugs when generic drugs were provided, listing treatment as having been for a more complicated diagnosis than was actually the case.
5. “Unbundling”—Using two or more billing codes instead of one inclusive code where
regulations require “bundling” of such claims. Submitting multiple bills in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.
6. “Code Jamming”—Inserting or “jamming” fake diagnosis codes to get insurance coverage.
7. Billing for non-covered services
8. Billing for services that are not reasonable and necessary.
9. Inappropriate balance billing—billing Medicare beneficiaries for the difference between the total provider charges and the Medicare Part B allowable amount.
10. Routine waiver of co-payments and billing third-party insurance only.
The complexity of managing a practice is not a walk in the park. As a Billing Consultant with PM&A, my job is to free doctors from the worries that can accompany running the financial end of a medical practice. I can review and streamline your billing department, train staff, and credential doctors with insurance companies, among other services.
Questions on how any of these might apply to your office? Contact me and I will let you know.
Next month – look for tips on nailing your Financial Consultations!!
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