Every year, an estimated $68-230 billion is lost to healthcare fraud in the US. Some of those dollars might be yours. Learn about common schemes designed to scam you out of your money and how to protect yourself from the most common forms of fraud.
Double billing
Double billing occurs when you are billed multiple times for the same service. It’s easy to lose track of what has been paid and what hasn’t, especially if you are facing an illness that includes multiple doctors appointments or procedures. You receive a bill, pay it, and forget about it. Six months later, you receive another bill and think, “I thought I paid this!” You check your calendar, see you did visit your doctor’s office that day, and think you must have mixed it up with another date of service.
How to Avoid It:
Check your explanation of benefits. Many insurance companies now have an app where you can access your past and present EOBs. If your balance does not match, call your doctor’s office or insurance company.
Keep a record of what bill you paid when. Sometimes your bank statement is useful, but it will only show that you paid a bill; it can’t tell you which one. If you are dealing with multiple bills, keep a record of which bill you paid on which date. Your bank statement can be useful as proof.
Phantom Billing
Phantom billing is billing for services not performed at all. These are often found in lengthier bills with multiple items that are easy to overlook, especially if they are low dollar amounts individually. You’d probably notice if someone charged you $5,000 for a hearing aid you never received, but you might not notice an extra $50 charge for an audiology test you didn’t receive during a hearing evaluation that involved multiple tests.
How to Avoid It:
Watch your bill. Did you receive all the services it lists? If you aren’t sure, you can call the office and ask for clarification. In the above example of an audiology test, you could call and say, “I see a charge for something called tympanometry, but I am not sure what that is. Can you explain it?” When they describe the test, you should remember having it done. If you don’t, you can tell them you don’t remember it and ask them to check the chart. Sometimes mistakes happen and it could be an accident. If they insist the test is in your chart, but you are certain you did not have it done, call your insurance company.
Upcoding:
In many countries including the U.S., medical billing is done by assigning diagnosis codes (ICD codes) and procedure codes (CPT or HCPCS codes) to a patient. The diagnosis code says what is wrong and the procedure codes say what was done about it.
To get paid more money, some providers or hospitals will bill a more expensive code when a cheaper service was performed. One of the most common forms of upcoding is billing an office visit at a higher level than was performed. An office visit can range from low complexity to high complexity. An upcoded office visit means a higher complexity office visit was billed while a low complexity office visit was performed. The level of office visit is not always straightforward and different coders will sometimes view these differently; it’s not always fraud.
Time-based codes are also often upcoded. A therapist spends 40 minutes with a client and bills an hour visit instead of the appropriate 45-minute visit. Or they will upcode a diagnosis code to justify more treatment than what is medically necessary. Another way to upcode these services occurs when group therapy is billed as individual therapy, which is fraud that falls somewhere between upcoding and phantom billing.
How to Avoid It:
It is much harder for those who are not professional medical coders to detect upcoding schemes. As always, check your billing statements and explanation of benefits. Time-based codes are the easiest to spot because you will know if you did not receive the time listed on the code description. (It does not have to be the exact time, just close to it. There are different rules for different codes, but generally, over half the time from one time-based code to the next higher time is accepted. So if your therapist saw you for 54 minutes, they can bill for the hour instead of the 45 minutes.) Group-based services billed as individual services are also easy to spot.
If you did not receive these types of services, but still suspect something with your bill is not correct, discuss your concerns with the billing office or your insurance company.
Unbundling:
Unbundling is a form of fraud that occurs when codes are billed together that shouldn’t be. Reimbursement for multiple codes is often found in one code. Laboratory tests are frequently targeted for unbundling. Say your doctor wants to check your hemoglobin and hematocrit. That’s one test. But say he wants to do a complete blood count, that’s a test known as a panel. Panel tests include multiple tests. The most frequent panel tests are complete blood counts (CBC) and basic metabolic panels (BMP). Billing for each component of the panel instead of using the appropriate panel code results in higher reimbursement but is inappropriate billing.
How to Avoid It:
Unbundling is often caught in the claims processing cycle with insurance. If your provider is in-network and something is unbundled, you should not be billed for it. If they are out-of-network, they may send you a bill for something insurance denied. If you do not understand why a code is denied, call your insurance company to find out why.
Not every unbundling scheme will be caught through insurance. If you saw a doctor for one or two straightforward things, but see a long bill, that’s a red flag. If you aren’t sure, call the billing office or your insurance company.
Conclusion:
Hopefully, you will never be in any of these situations, but if you are and calling your insurance company or billing office does not resolve the issue, consider talking to a billing advocate or an attorney.
Sources:
https://www.bcbsm.com/health-care-fraud/fraud-statistics.html