Anecdotes and real case studies ripped from the headlines about what doctors did which got them into trouble either with Medicare, HIPAA, The Office of Inspector General (OIG) or worse the FBI. The case studies are true stories of medical professionals: Some are about providers just like you trying to navigate the complex maze of the medical billing process. This guide will help you recognize the red flags and triggers so you can avoid a Medicare Audit. Learn about common problems that plague medical practices. Discover what your peers have done right and what they have done wrong. Avoid the costly billing mistakes and practice mismanagement showcased in Medical Billing Horror Stories. With the changes, challenges and uncertainties facing the Healthcare industry you can’t afford to miss this information. If you submit even one claim for reimbursement this is a must read!
Health care fraud is on the rise. As with any field, criminals try to cheat the system, and the government is cracking down to prevent it. Fraud costs taxpayers millions of dollars. My goal is to help doctors identify what their peers have done right and wrong. I have provided case studies on what doctors are doing in their billing practices, and also, I have included some red flags and audit triggers so doctors can avoid billing incorrectly. This book was not initially intended as a medical legal thriller, but what you are about to read are true accounts of medical billing horror stories that have been ripped from the headlines. If you want to hear what happened to the nurse who posted a narrative and a patient’s confidential x-ray on Facebook or a group of doctors who marketed patients in a rent-a-patient scam and performed unnecessary operations, then this book is for you.
The cases presented within these pages are true stories of medical professionals: Some are about providers just like you. Many doctors are just trying to navigate the maze of the medical billing process. Without a clear understanding of coding requirements, some thought that if they only bill just 99213’s, they could stay under the radar. What they didn’t expect is that by doing this and not varying their coding appropriately, they were raising red flags about their billing practices which led to them being audited by Medicare. Within these pages are case studies of providers that agreed to split a fee with another provider, or entering into a business agreement with another doctor or a hospital. They thought, “Well, everyone is doing it.” What they, too, didn’t expect is that the Office of Inspector General (OIG) eventually investigated them. Also, there are case studies about providers who have committed fraud, and thought, “Well I won’t get caught.” However, they were investigated and the FBI convicted many of fraud.
The case studies have all been grouped by specialty to simplify and illustrate what your peers have done. Some of these cases, as a result of audit findings, resulted in doctors having significant financial impact such as having to repay Medical Billing Horror Stories
Medicare or other 3rd party payors. Some doctors also had significant fines in addition to refunding money back to Medicare and some cases where doctors were faced with criminal and civil penalties including incarceration. Doctors have a legal obligation to not only treat their patients appropriately and with medical necessity but also to comply with the health laws and the authorities who oversee the laws, including but not limited to: HIPPA, Department of Health and Human Services, Office of Civil Rights, Centers for Medicare and Medicaid Services, and the Department of Justice.
Submitting claims to a third party for reimbursement exposes doctors to a litany of scrutiny. Doctors and other healthcare providers need to read these cases in order to learn the ins and outs of medical billing. Specifically, they must understand how to avoid an audit, prosecution, and the civil and potential criminal penalties for violating the law.
Due to the complexities of medical billing, the insurance marketplace and constant changes to both reimbursement and insurance coverage, providers often do not know how much they are going to be paid for care. Doctors must understand what to do in order to receive timely and accurate payment for their care, while avoiding submitting claims that may result in audits or fraud alerts. If doctors learn to navigate the billing maze, they will be able to focus on providing quality medical care for their patients. Compiled in this book are some of the 130,000 separate Medicare regulations and policies, and I have explained them in simple terms to assist in navigating the healthcare maze.
This book was current at the time it was written; however, Medicare policy changes frequently. Links to the source documents, with references, can be found in the back of the book.
In my years as a healthcare consultant, my zeal to communicate these Do’s and Don’ts of practice management to doctor’s has made for some very heated discussions. My knowledge about billing rules and regulations and Medicare Guidelines has not always made me popular with providers. To be clear, I didn’t create the laws or rules so please don’t shoot the messenger. As a healthcare consultant, an expert in reimbursement, and the current president of a successful medical billing service, I thought I had seen it all.
Sharon Hollander is an author, entrepreneur, and healthcare consultant in the area of practice management. She is also the president of STAT Medical Consulting. She graduated with a bachelor’s degree in psychology and physiology from York University in Toronto, Canada. She lives in the West San Fernando Valley in Southern California with her Labradoodle, Jason, who manages his own company at www.petjason.com. Visit Hollander online at www.sharonhollander.com.
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