Medical billing frauds are mostly related to medical insurances. In the US, such frauds may pertain to Medicare and Medicaid. Many people connected to health care sector may be involved in such frauds. The list of possible fraudsters includes beneficiaries, billing department personnel, recruiters, health care providers, and companies that offer medical services. Quite often invoices are raised for services that were not rendered to the beneficiary. Likewise, fraudulent bills may include medicines that are not prescribed for the beneficiary covered under medical insurance. Beneficiaries claim reimbursement of such bills, which might relate to somebody else’s medication. Such inflated bills may also be raised to fleece the beneficiaries.
At times cost of treating ailments that are not covered under any medical insurance, or costs of other services related to health care that do not come under Medicare are recovered by beneficiary through invoices that mention other ailments that are covered. This defeats the purpose of having specific coverage in medical insurance policies and Medicare. Health care facility may raise separate bills for procedures that are already covered under some main billing item. The effect of such unbundling is that the invoices get inflated. Such frauds are obviously felony. They happen with connivance of some medical professionals, and other personnel in billing department of the health care facility. Since legal implications of such frauds are quite serious, health care facility needs to take necessary measures for preventing medical billing frauds.
For starters screening every employee at the time of recruitment is advisable. Background checking of the prospective candidate is a must. It is also necessary to verify the billing certificates produced by the candidate. In addition to this precaution, the health care facility can implement a foolproof system that requires compliance at different stages so that possibilities of medical billing fraud are remote. Somebody from administrative department should be given the responsibility of ensuring regular compliance with the system. This person should also have powers to deal severely with any fraud that may be detected. It is necessary to explain the entire procedure, and various checks integrated in them to every employee. The system should also ensure that an employee can report any abuse by superior without fearing any backlash.
In addition to above measures, the health care facility can ensure that all the rules and regulations stipulated under Health Insurance Portability and Accountability Act (HIPPA) are followed. HIPPA is a US law. It relates to health related information about a patient. It also has provisions relating to patient’s privacy and security of relevant information. HIPPA therefore stipulates that information about a patient such as the patient’s name, medical history, address, etc.. be protected. Passwords that guard such information should be kept a secret so that unscrupulous people do not learn about any patient’s case history. Placing fax machines in places that do not allow general public to access them is another way to prevent medical billing fraud. It is advisable to send encrypted mails relating to the patient rather than sending mails without any security precaution. A confidentiality agreement with severe consequences for breach can be entered into between the facility and the medical billing personnel. Such precautions are necessary even if a third party’s services are being availed for medical billing. Relevant clauses can then be incorporated in the contracts for such services.
