The Affordable Healthcare Act has resulted in more funds being paid to help fight fraud. Fraudulent medical claims are at an all-time high, resulting in billions of Medicare and Medicaid funds paid to these claims. As a medical biller, it’s partially your responsibility to identify fraudulent claims and flag them for the fraud department. With computers doing most of the flagging, some billers are wondering what’s happening to those legitimate claims that are flagged as fraudulent, but aren’t actually fraud?
Computer Error
When a patient or doctor is attempting to defraud Medicare or Medicaid, computers can sometimes pick up on this fraud. The increase in the fraud detection budget has resulted in computer systems that are able to detect some common fraud practices.
These fraudulent practices include:
- Services billed after a person is deceased.
- Services claimed to be performed on persons not old enough to receive that service.
- Gender based services – billed to the wrong gender. For instance, if a vasectomy was claimed to be performed on a woman.
- Services claimed to be performed on a person not able to receive that service due to medical or surgical history.
Because computers are able to scan and detect this fraud, it means the medical biller won’t have to manually flag a number of these cases. That makes your job a lot easier. Still, a simple inputting issue can cause a computer to error. The resulting conflict means that the practitioner will be forced to pay back the Medicaid/Medicare funds paid to them. For example, if a name is gender neutral, like Jessie, and someone accidentally marked them as female, when the person’s gender is actually male, they could be auto-scanned as fraud after a vasectomy.
The only way to combat this issue is to keep good bookkeeping practices. People who do medical intake are urged to double and triple check their paperwork, before formally submitting a patient into the computer. This is going to ensure that they’re not hit with an unnecessary fraud audit and forced to pay back funds.
Plus, this kind of oversight helps to identify significant insurance issues, like if brand-name medication isn’t preferred. If a patient suffers from high cholesterol, the prescription drug Crestor is their only hope for relief. If a doctor writes a prescription for full-priced Crestor, the patient may not be able to afford their prescription. Their insurance may not cover the full cost and the out-of-pocket cost may be too much for the patient. The patient is only covered to buy generic Crestor and the doctor should prescribe it.
Appealing an Audit
If you’re met with phone calls from angry providers, ensuring you they’ve been falsely accused of fraud, you’ll need to direct them to file a RAC appeal. RAC stands for Recovery Audit Contractor and it’s the demand for a refund that’s sent to providers when fraud is detected. It’s not your job to assist with the appeal and it is okay to let the practitioner know this. Oftentimes, these phone calls do not go to medical billers or coders, but instead to the fraud department.
Unfortunately, it can be an added expense to practitioners to appeal these cases. They often give up, because they’re not experienced enough to read the RAC files. This isn’t something that’s your fault, as a medical biller, but it should make you understand that diligence is needed when flagging an account as fraudulent. You must be certain you’re taking the right steps.
Identifying True Fraud
These days, medical practitioners and patients are devising all new schemes to collect money from insurance companies, Medicaid, and Medicare. As a medical biller, it’s important to take note of these schemes and any new trends. This is going to help you truly identify when a fraudulent claim comes across your table.
