Physical Therapy CPT Codes & Billing Guidelines 2022

physical therapy cpt codes

Physical therapy is one of the services that can improve a patient’s health through physical activity and muscle movement.

A physical therapist will use physical therapy CPT codes to describe the services they provide to assist patients in regaining and maintaining their health. For instance, 97140 is used as a manual therapy CPT code. CPT 97014 is used to indicate the performance of modality therapy.

Practitioners must use the correct physical therapy CPT codes to reimburse the service. Regarding payment for medical or health services, the CPT codes used for physical therapy evaluations may differ from those used during home visits. The reason is that home-visiting therapists cannot provide a comprehensive range of services.

The present article contains information and a discussion of these coding principles. So, continue reading to learn important guiding principles related to physical therapy CPT codes.

Physical Therapy CPT Codes: Evaluation

Physical therapy evaluation is a dynamic procedure denoted by physical therapy CPT codes. The process assists physical therapists in making treatment decisions based on clinical data gathered during treatment. In this iterative process, the physical therapist uses the information gathered during the examination to make clinical decisions. Evaluation includes taking a thorough medical history, conducting a system review, and directing tests and measurements.

Then, a physical therapist will review the exam results, make a physical therapy diagnosis, determine the prognosis, and create a comprehensive care plan.

The following paragraphs will discuss how to code a physical therapy evaluation.

Physical therapy evaluation outcomes may be reported using the following physical therapy CPT codes:

  • 97161
  • 97162
  • 97163
  • 97164
  • 97140

A different set of codes is used for a home visit. Reporting the CPT G0151, CPT G0157, and CPT G0158 codes for home physical therapy evaluations ensures proper and accurate evaluations.

There are three forms of physical therapy evaluation, each with a distinct complexity level: low, moderate, and high. After determining the severity of the patient’s condition at any given time, several evaluation levels are performed.

The following physical therapy CPT codes are used to report on the various levels of evaluations:

CPT Code Description Complexity Ratio Time Duration Evaluation Procedure
97161 Physical therapy evaluation code that can be reported for minimal therapeutic complexity Low 20 minutes Evaluation with the patient’s family face-to-face (due to low complexity)
97162 Evaluation code for physical therapy that can be submitted for moderate therapeutic complexity Low 30 minutes Evaluation with the patient’s family face-to-face (due to moderate complexity)

 
97163 Evaluation code for physical therapy that can be submitted for high therapeutic complexity High 45 minutes Face-to-face evaluation
97164 Physical therapy re-evaluation – 20 minutes Face-to-face evaluation

Physical Therapy CPT Codes: Home Visits

There are three CPT codes for reporting home health physical therapy when a therapist travels to multiple locations to provide therapy services.

  1. CPT G0157 is for use by assistant therapists
  2. CPT G0159 is for establishing a therapy plan for hospice/home care
  3. CPT G0151 is for use by physical therapists

With the CPT code 97014 for physical therapy, the therapist can demonstrate the use of modalities and electrical stimulation in one or more locations. Stimulation would alleviate the discomfort and swelling while accelerating the healing process.

The type of electrical stimulation utilized will depend on the patient’s condition and the physician’s diagnosis. Since constant monitoring of the stimulation treatment is required, a physician can only record one stimulation process each day. On the other hand, non-physical stimulation treatments can be administered and reported on the same day.

Modifier for Physical Therapy CPT Code

A modifier 76 will be applied to the manual therapy CPT Code, i.e., 97140, if more services than stimulation are provided on the same day or day of services. Each of the service codes for the additional services can be recorded separately. It will display the number of non-electrical stimulation services performed on the same date.

Physical Therapy CPT Codes for Pelvic Floor

Physical therapy can be utilized to restore pelvic floor function. When physical therapy treats pelvic floor dysfunction, either CPT 90912 or CPT 90913 may be reported. The supporting documents must comprehensively describe the service, such as “exercise or therapy for the pelvic muscles.”

Physical Therapy CPT Codes for Different Treatments

The below table illustrates CPT codes billed for different therapeutic approaches:

Codes Explanation
97110 Therapeutic Exercise: Includes strengthening, ROM, endurance, and flexibility exercises
97112 Activities that retrain movement, balance, posture, coordination, and proprioception/kinesthetic sensibility
97116 Gait training includes sequencing, modified weight-bearing, and appropriate turns
97140 Manual therapy includes soft tissue mobilization, joint mobilization, muscular energy techniques, and manual lymphatic drainage
97530 “Dynamic activities” to improve function. Sit-to-stand training, bed mobility, step-ups/stair negotiating, hip-hinge training, squatting mechanics, tossing a ball, swinging a bat or golf club, automobile transfer training, and good lifting mechanics
97535 elf-Care/Home Management Training comprises ADL training, compensating training, safety procedures/instructions, food preparation, and assistive technology/adaptive equipment use

 

97112 CPT Code

CPT 97112 is among the most important physical therapy CPT codes. Neuromuscular re-education is a condition that can be coded with the 97112 CPT code for physical therapy. Neuromuscular re-education improves function and reduces the severity of impairments. Therefore, using these strategies will likely improve the difficulties and problem regions.

Exercise can enhance the connection between your brain and the muscles that contract in response to anxiety. The senses determine how much effort it takes to move the body and where the various bodily components are concerning one another. Treatments can be tailored to specific claims; just as therapeutic activities can be tailored to certain bodily regions.

CPT 97112 can treat stroke patients and those with neuromuscular transmission problems or muscle ailments. Outside-the-hospital orthopedic rehabilitation procedures can be reported using this code. The record must include specifics concerning the executed activities or exercises, such as what was anticipated to occur.

The permitted time for the reimbursement of the therapy is 15 minutes. According to CMS regulations, each patient must have an eight-minute direct connection with a single service unit.

The patient and a medical professional, such as a therapist, must communicate directly for this treatment to be effective. If the procedure goes longer than the permitted time, a 15-minute CPT code can be generated.

When neuromuscular re-education (CPT code 97112), massage (CPT code 97124), and joint mobilization (manual therapy CPT code 97140) are performed in addition to chiropractic care, modifier 59 must be applied.

See Also: New ICD 10 Codes for Pathology Billing – Is Your Practice Ready?

Conclusion

Physical therapy CPT codes provide payers with consistent information about the services and procedures they cover. The practice’s financial health depends upon its ability to submit clean and accurate claims using the correct CPT codes for billing. It is wise to hire an expert medical billing and coding firm, i.e., Precision Hub, to file your claims on time and expedite the reimbursement process. Our tried-and-true method employed by our skilled medical coders and billers guarantee accurate coding and timely payments. It expedites the entire procedure, so medical facilities receive the money quickly.

Contact us for efficient medical coding and billing services without wasting further time. Call us now: (888) 454-4325.

New ICD 10 Codes for Pathology Billing – Is Your Practice Ready?

pathology billing

ICD-10-CM codes are the most critical evidence that the services your practice provides are medically necessary, so it is crucial to know them. Your reimbursement request will be denied if you cannot provide evidence that the treatment was medically necessary. Hence, you will have to pay for it.

Being familiar with the new ICD 10 codes for pathology billing is essential.

This post sheds light on different aspects of pathology coding and billing codes.

Pathology Billing

On July 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed Medicare Physician Fee Schedule for 2023. The purpose of these modifications is to ensure that next year’s compensation for the technical aspect of pathology is more precise. Between 2022 and 2023, they wish to reduce payments for pathology by approximately 1%. There will be a reduction in the conversion factor by 4.4% to compensate for eliminating the 3% fee increase for 2022.

Pathology processes include the evaluation of blood, bodily fluid, or tissue samples taken from a patient and utilized to advise the treating physician. Typically, lab staff is responsible for preparing pathology and lab specimens and screening and testing them. However, it is the pathologist’s responsibility to ensure that lab results are accurate. The pathologist will examine or determine the significance of specific materials and tests. Such examples are blood and urine samples. For pathology billing, a pathologist can record the correct code from the E&M part of the CPT Manual if they meet CMS and AMA E&M guidelines and perform meaningful, individually identifiable face-to-face patient care services.

In 2023, there will be 78,496 ICD-10-PCS codes in use. It includes 331 new codes and the removal of 64 codes. Due to these changes’ impact on reimbursement, medical billing and coding services providers will need to get familiar with the new regulations.

According to the College of American Pathologists, thirteen (13) new CPT codes for digital pathology in Category III will be implemented on January 1, 2023. The CPT category III codes are a collection of temporary codes that can be used to collect data regarding services and procedures.

As per the new guidelines for pathology coding, codes 0751T through 0763T will be utilized to describe what clinical personnel performs when digitizing glass slides for the first diagnosis.

By digitizing glass microscope slides, a pathologist can do an examination remotely, alone, or with the assistance of artificial intelligence (AI) techniques. The Category III add-on pathology billing codes 0751T-0763T may be reported in addition to the right Category I service code when digitizing glass microscope slides and reporting the Category I code for the primary service. These add-on codes can be reported alongside the Category I service code.

Suppose a code from Category III is available. In that case, it should be reported in place of an unlisted code from Category I. Using Category III codes. Physicians, other qualified healthcare professionals, and insurers can identify services and procedures for clinical effectiveness, utilization, and results.

The new digital pathology add-on codes are related to CPT 88305, and 12 other commonly reimbursed pathology procedures (Level IV-Tissue Exam). Only cases in which the newly introduced add-on codes were used for clinical diagnosis should be reported.

The below table shows important codes related to pathology, digitization of glass microscope slides, and microscopic and gross examinations:

Codes Level or Groups Usage in Conjunction with
+0751T Level II

 

 Separately with the primary procedure code

OR

With 88302
+0752T Level III

 

 Separately with the primary procedure code

OR

With 88304
+0753T Level IV

 

 Separately with the primary procedure code

OR

With 88305
+0754T Level V Separately with the primary procedure code

OR

With 88307
+0755T Level VI

 

 Separately with the primary procedure code

OR

With 88309
+0756T Group I Separately with the primary procedure code

OR

With 88312
+0757T Group II Separately with the primary procedure code

OR

With 88313
+0758T Histochemical stain on frozen tissue block Separately with the primary procedure code

OR

With 88314
+0759T Group III Separately with the primary procedure code

OR

With 88319
+0760T Immunocytochemistry or immunohistochemistry Separately with the primary procedure code

OR

With 88342
+0761T Immunocytochemistry or immunohistochemistry per specimen Separately with the primary procedure code

OR

With 88341
+0762T Multiplex antibody stain procedure Separately with the primary procedure code

OR

With 88344
+0763T Single antibody stain procedure Separately with the primary procedure code

OR

With 88360

Pathology Coding

More than 1,400 new diagnostic codes are added to the ICD-10-CM codes for 2023. All payers must be provided with the new mandatory codes. Since these codes suggest the necessity of seeking medical treatment, inappropriate use of the codes may result in claim denial and loss of reimbursement for services rendered.

Here are important highlights of the new pathology billing codes:

  • Expansion of the OB/GYN code (over 400 new codes)
  • Code for concussions and other brain injuries as well as dementia (over 100 new codes)
  • Code for methamphetamine overdoses, indicating new Category for meth poisoning
  • Codes for electric bike injury, allowing for additional information about the accident

In addition to the above-described code extensions, the following specialty and conditions will be coded significantly differently:

Code Series Description
I25.- Atherosclerosis
F10.9 Alcohol and other substance use
C84.4 T-cell lymphoma
G71.03 Limb-girdle muscular dystrophy
B37 Candidiasis (vulva and vagina)
E87.2 Acidosis
D68.0 Von Willebrand disease
M93.0 Slipped upper femoral epiphysis
E34.3 Short stature
M62.5A Back’s Muscle wasting
P28.- Newborn sleep disorders
D59.3 Hemolytic-uremic syndrome

Preparing for New ICD 10 Codes for Pathology Billing

Utilizing the appropriate diagnostic and procedure codes when submitting claims to insurance companies for pathology-related medical services is crucial. Outsourcing your pathology billing to Precision Hub is the best approach to fulfilling any new ICD coding regulations for pathology billing. We have years of experience in the business, allowing us to monitor all aspects of the pathology coding process and assist you in better managing your revenue cycle.

See Also: Preventive Medicine Services Coding Guidelines

Conclusion

There is no practice where coding does not significantly influence the revenue cycle and bottom line. With the assistance of Precision Hub’s coding services, you can rest assured that your claims will be processed correctly from the beginning.

Precision Hub provides ICD-10-compliant coding services to its customers as a medical billing and coding outsourcing leader. Our coders apply the ICD 10 Pathology Billing Codes that best depict the patient’s treatment. We provide you with the most recent medical codes for the services you provide to your patients per AMA and CMS regulations.

Schedule your meeting with us to learn more about our professional coding assistance.

 

How to Optimize the Denial Management Process?

denial management process

When effectively managing healthcare claims, one of the most important things to do is to establish a system that efficiently handles rejected claims. The majority of medical practice administrators are concerned about work allegations, particularly when they are denied. It is necessary to establish an efficient method for handling medical claims to resolve these claims. Even minor adjustments can significantly impact the amount of cash your practice’s revenue cycle generates.

Denied claims can be avoided by creating an effective denial management process that contributes to the bottom line. Your practice needs sound analytics, embracive technology, workflow automation, education, services, and professional support to achieve an efficient process.

Continue reading this post to learn more about the denial management process. The article presents some effective tips for denial management in medical billing.

So, let’s explore how to improve denial management in healthcare.

Denial Management Process

The denial management process is a closed-loop business procedure that entails investigating each denial and conducting root cause analysis to determine why each claim was denied. It involves analyzing denial trends to determine how payers behave, working with insurance companies and payers to overturn denials, and implementing procedures to prevent future denials. Denial management impacts the entire revenue cycle, from the front end (denial prevention) to the back end. How denied claims are processed impacts cash flow, reimbursement, and collection costs, as well as the teams responsible for patient access, clinical care, and health information management.

Denial Management in Medical Billing

Denial Management in Medical Billing

Having an efficient denial management process is crucial for your practice’s success. Here are some tips on increasing the effectiveness of bringing in money and handling denied claims correctly.

Maintain a Streamlined Procedure

It is essential to maintain a streamlined process to keep track of denied claims in real-time. It helps monitor the status of claims throughout the entire procedure. You can quickly rectify the issue and resubmit your claim if it is denied. Denied claims that take a long time to resolve will significantly delay your practice’s cash flow. You can even avoid being required to resubmit within the specified time frame.

Identify Weak Areas

Utilizing denial management software can be extremely beneficial because it relieves your employees of the responsibility of reviewing claims and allows you to identify areas where necessary changes are required. You may also need to correct the coding errors or keep better track of patients and treatments to ensure that each plan covers them. Taking measures to address these concerns will increase the number of cleaner claims.

Employ Claim Scrubbing

Claim scrubbing examines billing codes for errors before sending them to insurers for payment. As a result, significantly fewer claims are denied or rejected, facilitating on-time payments. Incorrect codes cause most denials; fixing them can save time, money, and other resources.

Implement Automated Verification

One of the most common reasons for denied claims is that the patient’s insurance did not cover the service. It can occur for various reasons, including when the patient changes insurance plans without notifying the clinic or when the patient’s coverage expires. In any case, this error could result in significant financial loss. In healthcare, optimizing service time and making a profit is only possible by verifying coverage. Automation is a crucial step toward an efficient denial management process.

Outsource Denial Management

Given the importance of denial management to a business, it is best to outsource it to a company like Precision Hub, which specializes in Revenue Cycle Management systems. When outsourcing medical billing, you entrust the revenue cycle to individuals with extensive training and education. Medical billing should be outsourced if you are experiencing problems with your revenue cycle.

Apply Technological Advancements

Technology is necessary for proactively managing and preventing denials. Errors can be avoided, processes can be streamlined, and efforts to prevent and manage denials can be concentrated in the right areas if there is a seamless flow of information between departments. Real-time analytics with data-driven insights and robust reporting with root cause analysis further aid in optimizing the denial management process. Automation or other technological applications contribute significantly to managing front-end denials, thus ensuring a proactive denial management process.

To remain competitive in today’s advanced healthcare system and eventually reduce the likelihood of denials, you must act and implement the abovementioned strategies.

Denial Management in Healthcare

As the healthcare industry transitions toward value-based care, denials management will be useful for determining and tracking all the costs associated with value-based contracts. It is because denial management is based on the payment decisions made by insurance companies. When all aspects of patient care are considered, the financial success of many practices will depend on how well they handle denials, which distinguishes between losing and winning a contract.

Leaders in healthcare finance should continue to invest in denials management and emphasize its significance to the overall financial strategy. A successful program will generate an immediate return on investment (ROI) and position the healthcare organization to profit from long-term payment trends. By utilizing denial management systems, it is possible to compensate for losses since it is easier to check claims for errors and collect data before submission.

See Also: Denial Management Services for Emergency Medicine Physicians

Conclusion

Establishing an effective healthcare denial management system is the most important thing to increase profits. There are numerous reasons why the healthcare management system rejects increasing claims. Your claim may be denied if there are billing or coding errors. Practices must resubmit their claims to receive the payments. The most effective way for a practice to improve its bottom line is to optimize its denial management process and submit more accurate claims. Poor management of the claim processing can negatively impact the revenue cycle.

Precision Hub has a team of skilled medical billers and coders ready to assist you in maintaining a smooth revenue cycle. Our mission is to assist physicians in streamlining their medical billing to be paid more quickly and easily. Claim denials occur for numerous reasons, resulting in financial losses for healthcare professionals. Schedule a demo now to learn more about how we handle denied claims.

You can contact us and see how we can assist you in optimizing your denial management process. 

Why You Should Conduct Medical Billing Audit?

medical billing audit

A medical billing audit is a systematic process that employs in-depth inquiry and assessment to identify issues in the clinical documentation of provided services. Medical audits bring these issues to light. If these issues are resolved, accounts receivable will decrease, and revenue cycle management will be more successful.

A medical billing audit permits medical facilities to examine their billing procedures, the significance of their codes, and how they submit claims. The audit ensures that their system is functioning properly and helps them determine if they need to upgrade for improved performance. In addition, audits of medical bills reveal errors that, while not a problem, could become one in the near or distant future.

Let’s discuss why your practice should do medical billing audits.

Medical Billing Audit

A medical billing audit is a planned evaluation of the efficacy and dependability of clinical documentation and the complete medical billing procedure. The approach entails a comprehensive assessment of the practice’s health records and the medical billing data submitted to payers. It ensures the practice is aware of, tracks, and corrects any incorrect billing practices.

During a billing audit, the practice may be required to provide the following:

  • Clinical records (medical records, x-rays, lab reports)
  • Financial records (EOBs, accounts receivable ledger, and entered charges)
  • Policy-related documents (if requested by providers or the government)

The electronic health record (EHR) allows you to view these records.

Audits are conducted either before or after claims are submitted to payers. These sorts of audits are known, respectively, as prospective audits and retrospective audits. Some practices prefer prospective audits for new providers while retrospective audits for the existing ones.

Medical Billing Audits Approach

Medical Billing Audits Approach

Medical billing audits examine all aspects of the billing procedure, beginning with insurance verification and proceeding through ICD and CPT coding, claim filing, payment posting, follow-up, and denial management systems, and concluding with follow-up procedures. Audits of medical bills examine the billing and coding solely. They do not consider the type or quantity of care, whether it was necessary, how much it cost, or what the provider provided.

Benefits of Medical Claim Auditing

Some of the important benefits of medical billing audit are listed below:

1. Improved Coding Compliance

Medical billing audits can assist in identifying errors, obtaining guidance on fixing problems, building trust among the coding team, and ensuring that the most recent procedure codes are utilized. Audits are required to simplify and standardize the medical billing process. Procedures for medical billing must comply with HIPAA. If they are not, a medical facility and its billing partner could be subject to severe issues, such as legal penalties that would harm their reputation and cost them money. So, to avoid losses due to noncompliance, audits are crucial.

2. Strengthened Denial Management

Audits can improve claim performance by lowering the number of denied claims. Claim denials have a substantial influence on the amount of cash that is available to a healthcare provider. The most common denials reasons include the following:

  • Not being able to provide required pre-authorization
  • Not having enough paperwork
  • Errors in patient data or procedure codes
  • Submitting a duplicate claim
  • Submitting a claim after the payer’s deadline
  • A medical procedure not being deemed necessary
  • Not being eligible because the payer doesn’t cover it
  • Using an out-of-network provider

A timely medical claim auditing can prevent the majority of problems that lead to denials by identifying and correcting possible concerns and preventing further ones from occurring. It helps the practice’s financial resources and earnings develop over time, which benefits it.

3. Better Staff Understanding

Audits help administrative employees understand their responsibilities and prevent them from becoming overly frustrated. A culture of compliance and a stable work environment are beneficial outcomes of audits that save the administrative staff from frustration. Audits set the norm for employees by instituting policies and processes that foster a compliant, stable, and enjoyable work environment.

Streamlining a medical practice’s workflow due to a successful audit has numerous benefits, including increased productivity, improved communication, and more efficient time management. Audits assist administrative personnel in ensuring that claims are accurate and presented properly. It ensures the prevention of billing and coding errors.

4. Boosted Practice Revenue

Medical claim auditing guards against billing and claims fraud. When practices have an internal system of checks and balances, it is simple to determine if they are prepared for ICD-10-CM compliance and use electronic health data effectively. As a result, there are lesser chances of denials that turn profits the practice.

5. Payer-Provider Relationship

The relationship between a payer and a provider is crucial, similar to that between a patient and a physician. A medical claims audit is also advantageous since it improves relationships with payers. Payers appreciate it when claims are properly filled out and submitted. An audit will reveal any outliers, allowing the practice to determine what is wrong before a large payer discovers an issue and requests an external audit. Payers appreciate fewer disagreements, strengthening the business relationship between the medical provider or billing agency and the payers or insurance companies.

6. Enhanced Patient Care

Audits of medical claims contribute significantly to the enhancement of patient care. The entire practice switches its focus to the quality of care it provides. As a result of an audit, the practice tracks and monitors the services and treatments it provides and trains its doctors to provide the best care possible to its patients. When patients have a better experience, the revenue cycle and outcomes improve.

See Also: Why Outsource your Medical Billing Services?

Conclusion

A practice should conduct frequent audits of its medical billing to determine how effectively and efficiently it processes claims. A medical billing audit is essential for your healthcare organization since it will reveal areas where you may improve as a provider. It enhances the precision and speed of writing medical records. Auditing medical practices frequently are advantageous for healthcare organizations in numerous ways. You must employ an expert auditor to avoid difficulties and optimize your revenue cycle management.

Join us, and we will ensure that the billing and coding procedure is filled with happiness. Our medical billing specialists at Precision Hub will expedite the entire billing procedure for you. We will optimize your charges, submit your claims, ensure that you are paid on time, lower your accounts receivable, identify underpayments, and boost your practice’s net collections, resulting in improved clinical outcomes and service expansion.

You will also be assisted by a client manager solely responsible for your account. Additionally, the staff will be available 24/7 to answer your inquiries. So, please don’t wait and schedule a meeting with us to learn about our expert services.

Why Outsource your Medical Billing Services?

outsourcing medical billing

Apart from clinical services, the most important aspects of a medical practice are billing for medical services and managing the revenue cycle. The majority of practitioners must decide whether or not to outsource their medical billing. The answer is a definite “yes”; however, the answer to this question depends on the size, scope, market conditions, and financial situations of individual practices. Do you want to know why you should outsource your medical billing and what to look for in an outsourced medical billing company to manage your medical bills? Continue reading this post to find the answers to your questions, as this article reveals all the important aspects of outsourcing medical billing.

Outsourced Medical Billing

In today’s complicated and rapidly expanding healthcare business, outsourcing medical billing has proven to be a significant strategic advantage for medical professionals. As a result of superior systems, cutting-edge technology, economies of scale, and experienced personnel with specialized knowledge and abilities, outsourced medical billing frequently results in more cost savings and better outcomes. An outsourced medical billing firm can help you establish billing process priorities. So, outsourcing is the simplest and least time-consuming strategy to increase the profitability of your medical practice. Investing much money and time in the billing process is vital.

Keep on reading to uncover the benefits of outsourcing your billing:

Keeps Doctors Focused on Patient Care

Medical personnel can concentrate on patient care by outsourcing claim filing and payer communication. They know professionals will handle billing and other revenue cycle management (RCM) tasks. Outsourcing allows them to spend more time and effort ensuring that their care is of the highest quality. If a physician is too busy with the business side of their practice, they cannot provide their patients with adequate care.

Cuts Down Labor Costs and Billing Mistakes

The practice is responsible for hiring, onboarding, and training billing staff when billing is performed in-house. On the contrary, professional billing firm ensures that the billers they employ have the necessary skills and knowledge to submit medical claims accurately. Medical billers with the essential knowledge and experience can ensure that your claims are submitted on time and in the correct format. Thus, outsourcing reduces the number of claims denied or rejected due to billing issues.

Amps up the Revenue Cycle

The top medical billing services have a system that allows claims to be submitted on time. Timely filed claims have a greater chance of being paid more quickly—the income increases when a practice transitions to an outsourced medical billing provider. Practices lose a significant amount of money annually due to denied claims. Using an effective electronic health record system and expert medical billing services reduces the likelihood of errors. It results in fewer denied claims. Moreover, unpaid claims are maintained in the system until they are settled.

Accelerates Insurance and Payment

When a competent establishment handles medical billing, there are fewer errors, reducing the time required to receive payments and reimbursements. Customers accustomed to the faster pace of today’s digitalized environment prefer streamlined processing solutions, increasing efficiency and generating more revenue.

Adherence to the Rules and Updates

Daily implementation of new coding and billing standards helps keep the medical industry current. Those on your staff responsible for coding and billing should be aware of the most recent regulations. Internal billers should be made aware of changes to industry regulations. In addition to government regulations, public and private insurance companies frequently alter the steps and criteria that must be met to receive reimbursement. When you hire a company to handle your billing, your insurance company will rely on that company to send your bills appropriately. Companies that outsource their work ensure compliance with HIPAA regulations and insurance standards.

Outsourced Medical Billing Company

Outsourced Medical Billing Company

An outsourced billing company offers automated software, quick recovery, and follow-up. A consistent cash flow contributes to a practice’s success and growth over time. An outsourced medical billing service can help you create value for your practice by keeping billing transparency and accountability under control. You can avoid the time-consuming and tedious medical billing procedure by employing a low-cost company like Precision Hub that performs excellent service.

Outsourcing Does Not Limit Your Financial Control!

It is a common misconception that outsourcing medical billing entails handing over a practice’s finances to an unknown third party and abandoning financial management. However, this is not the case. After a contract is signed, an outsourced billing team must focus on specific KPIs. It provides a very clear image of the money-making cycle that you control. A billing company undertakes to provide information in the form of detailed performance reports depending on its activities and outcomes. So, you can handle problems with payments, delays, and other financial concerns without micromanaging.

Picking the Right Outsourced Medical Billing Firm

You must select the appropriate billing service for your practice. Several factors must be considered, including a company’s medical billing services and the rate at which insurance claims are processed. These are both essential considerations. It is also vital to choose whether monthly financial reports will be issued, their quality, the training their team receives, and how to reach the professionals who manage current accounts receivable (A/R). Considering these aspects, Precision Hub is the right choice. It provides a complete picture of the clinic’s performance. Using the drill-down function of the BI custom reports that we offer at Precision Hub, you can obtain specific data regarding the number of patients, the status of medical credentialing, and more.

See Also: How to Attain Accurate Billing Solutions

Conclusion

There are numerous advantages associated with outsourced medical billing. Healthcare providers can save considerable time and resources by outsourcing their medical billing. They can devote more time and attention to providing high-quality patient care while improving patient flow and overall satisfaction.

In medical practice, billing errors are the leading cause of revenue loss. Outsourced medical billing service can ensure that it meets certain quality standards. Outsourcing thus reduces the likelihood of costly errors and increases profits by simplifying work. Precision Hub ensures that all invoices are received on time and contain the correct information. We know the need to complete documents accurately so insurance companies can avoid delays or refuse claims. Our staff has been trained to do medical and coding activities involving patient demographics, CPT, and ICD codes with modifiers. So, book your consultation now and outsource your medical billing to Precision Hub to reap maximum benefits.

How to Attain Accurate Billing Solutions

accurate billing solutions

Are your practice’s income or reimbursements decreasing? Inaccurate billing and coding may be the source of the issue. A healthcare practice must generate revenue and maintain a healthy financial growth rate for effective operation. Coding and billing are the foundations of revenue cycle management (RCM). They ensure that doctors are paid according to the insurance company’s standards for their services.

However, when it comes to invoicing for medical services, physicians encounter numerous obstacles. If a billing mistake occurs or the error code attains, the payer might deny or reject claims for the tiniest reasons. These denials and rejections of claims impact how much doctors are compensated for their services. When practices adopt improper billing procedures, it is detrimental to the medical practice and the patients. Thus, attaining accurate billing solutions is crucial for streamlining the practice.

Today’s post is about accurate billing solutions and tips and tricks for precise billing and coding. It sheds light on avoiding coding errors and ensuring accurate billing. So, keep reading to find out how to ensure accurate billing for your practice to generate maximum revenue.

Accurate Billing Solutions

Medical billing in the modern world can be so intricate that it can take weeks or even months to complete. This is because the procedure is occasionally difficult to comprehend. The process must be constantly reassessed because it is difficult to balance the internal workflow of your practice with the expectations of your claims processing vendors and external clearinghouses.

Coding and billing are essential components of the modern medical industry. These essential tasks must be appropriately performed because they relate to the patient’s health and safety, the surgeries’ effectiveness, and timely payment. When it comes to invoicing and coding for medical services, precision is crucial. Medical coding involves familiarity with medical terminology and fundamentals of anatomy and physiology. If medical billers lack this knowledge, they may send insurance companies bills containing incorrect medical conditions or diagnoses. Underpayments or overpayments would be detrimental to the financial health of medical practices. They could face legal consequences if they were discovered to breach government regulations and private-payer laws. Medical billing and coding errors can result in substandard care and improper payment. Accurate billing ensures that patient bills are precisely analyzed and managed and that practices receive full payment.

accurate billing

Steps for Obtaining Accurate Billing

Attaining accurate billing solutions can be difficult for healthcare professionals since it entails a multitude of codes, rules, and guidelines. However, with the right approach, accurate billing is achievable. Listed below are some steps that will assist you in achieving accurate billing solutions:

  • Understand the billing codes: It is crucial to stay current with the most recent billing codes and laws, as medical billing codes are always evolving. This will guarantee that your billing is compliant and correct.
  • Utilize billing software: Investing in software for medical billing can assist in automating the process and reduce the likelihood of human error. Look for user-friendly, adaptable software that includes an error-checking mechanism.
  • Verify insurance coverage: Verify the patient’s insurance coverage before administering treatment to guarantee that the service will be covered. This will aid in preventing denied claims and reducing the chance of attaining an error code.
  • Have an effective follow-up system: It is essential to follow up on unpaid and denied claims to ensure that you receive payment for services rendered. One or more staff people be employed to review claims that have been in the system for an extended period and identify any missing information that could result in claim denial.
  • Have an efficient audit process: Regularly review and audit your billing process to identify any errors or areas for improvement.

By following these steps, you may increase the accuracy of your medical billing and ensure that you receive accurate payment for the services you render.

Attain Accurate Billing Solutions with Precision Hub

The success of any practice depends on being paid in a timely and precise manner for the services rendered, making accurate billing solutions a top priority. Precision Hub provides accurate billing services. From invoicing and payments to financial reporting, Precision Hub’s state-of-the-art technology ensures that all billing operations are carried out efficiently and accurately. With Precision Hub, you can rest assured that your billing process is in good hands, leaving you free to focus on providing the finest care to your patients.

When you outsource your billing to Precision Hub, you will get the following benefits in addition to accurate billing:

  • Competitive Pricing
  • Higher Reimbursement
  • Timely Payment
  • Faster Turnarounds
See Also: How Accurate Coding Can Save Your Revenue?

Conclusion

Coding and billing are frequently viewed as revenue-generating operations in the medical sector. Obtaining accurate billing solutions is vital, ensuring you receive timely payment for your services. The process can be complex, but by understanding the billing codes, using billing software, verifying insurance coverage, and having a good follow-up and audit process, you can improve the accuracy of your billing and reduce the risk of errors. With the right approach, you can achieve accurate billing and focus on growing your practice. By keeping these steps in mind, you can take control of your billing process and ensure that it is accurate and efficient.

Outsourcing can make it easier to keep track of things, save operating expenses, enhance speed and accuracy, and reduce the likelihood of problems occurring with costly-to-maintain in-house technology. For accurate billing, you can rely on Precision Hub, as we use cutting-edge technology to streamline and correct all aspects of the billing process. Schedule a free demo today to learn more.

Guide to Medical Billing and Coding Best Practices

practice medical billing

Precision is crucial when it comes to medical billing and coding. Even little errors can result in a payer rejecting a claim, causing delays and lost revenues. Since coding regulations are frequently updated, healthcare experts can avoid under or over-coding or using outdated codes. Due to denials, billions of dollars are lost annually.

The practice’s medical billing can be improved with automation. Using software-driven and automated methods can aid in simplifying the already complex field of medical coding or billing. Claims processed correctly on the first attempt expedite the settlement process, resulting in faster and greater reimbursements. Providers can generate more accurate financial estimates, spend less time reworking denied claims, and inform patients more precisely of their out-of-pocket costs.

This post intends to offer guidelines for best practices for medical billing. Let’s explore important aspects of medical billing for private practice.

Coding and billing are essential components of the revenue cycle in the healthcare industry because they ensure that patients and payers pay for the services providers render. Depending on the intricacy of the services, how organizations handle claim denial management, and how a patient’s financial obligations are collected, medical billing and coding can take anywhere from a few days to many months.

Comprehending the fundamentals of medical billing and coding assists doctors and other personnel run a seamless revenue cycle. It also helps in getting compensated for the excellent treatment they provide.

Stress, rage, and other negative emotions can result from billing issues affecting patients and doctors. When a provider fails to provide the correct demographic information about a patient or verify that the patient is eligible for the treatment, expensive denied claims may occur. Errors can cause delays and additional labor when claims must be resubmitted. So, adhering to the best practices for medical billing is crucial to limit the likelihood of making errors.

Let’s examine some of the most effective approaches for your practice’s medical billing process.

Best Practices for Medical Billing

The following are the important areas to focus on for improving your practice’s medical billing process.

practice medical billing

Make Patient-Friendly Medical Billing statements

Patients are likely to find the medical billing procedure difficult to comprehend. Since industry expectations have shifted in a way that makes it essential for doctors to take a patient-centric approach to this process, you must remain accessible and make your statements patient-friendly.

Maintain a 95% Clean Claim Rate

Your clean claim rate is the proportion of your medical practice’s claims that are approved and paid on the first try. When the percentage of clean claims increases, practice will spend less time determining why claims were denied, organizing payments, and resubmitting claims.

Analyze your Payer Reimbursements

Numerous medical practices rely excessively on payers to pay the entire amount on each claim they submit. Unfortunately, this is only sometimes true. Contrary to what you may believe, underpayments occur frequently. If you invest time and money into determining whether your payments are accurate, you will minimize revenue loss and learn a great deal about how your practice handles revenue.

Ensure Accurate Claim Submission

If you double-check your claim before submitting it for the first time, you will save time editing and resubmitting it. It is estimated that up to 80% of medical invoices contain errors, which take a few weeks to resolve and resubmit and result in unpaid medical providers. You may improve the efficiency of your practice’s medical billing process by ensuring that claims are accurately filled out and eliminating typical errors, such as providing the incorrect patient or insurance information and submitting duplicate claims.

Maintain Medical Billing Regulations

It is essential to have a thorough awareness of the current standards governing the process to ensure that medical billing and coding procedures are of the greatest quality. Keeping up with the ever-changing standards enables the creation of a streamlined approach that reduces the likelihood of rejections and medical billing changes. If you remain current on medical billing regulations, your ability to generate revenue from your medical practice may improve.

Look for Improvement

Your healthcare practice will continue to expand if you discover new ways to improve your skills. Finding ways to enhance the medical billing process continuously is one strategy to maximize revenue. It is crucial because the healthcare industry is constantly evolving. It’s important to remain current on the latest medical billing laws, but it’s equally important to analyze past performance to identify areas of inefficiency and devise solutions. Using key performance indicators (KPIs) to monitor performance can help determine how precise and effective past performances were and where they could have been improved.

Medical Billing for Private Practice

Accuracy is required to ensure that medical claims are completed, sent, and paid within the allotted time frame. Having best practices improves accuracy, which in most cases results in shorter collection times and a higher claim approval rate. It is crucial to plan to investigate your current billing practices to determine if there are ways to enhance the relevant KPIs. Identify improvements that reduce billing times, increase cash flow, and make it simpler for insurance companies to approve claims.

See Also: Advance Radiology Medical Billing Guide

Conclusion

Your medical practice cannot provide quality patient care if it cannot generate sufficient revenue. Suppose you have an efficient medical billing system in place. In that case, your medical practice will remain financially stable, allowing you to focus on your primary objective, improving your patient’s health. As technology and payer expectations evolve, the practice’s medical billing processes must also evolve. If your medical practice fosters a culture of adaptability and continuous improvement, it will be able to adapt to the changes in the healthcare system.

If you are running behind on billing or can’t keep up with the current rules, consider outsourcing your billing. Medical billing companies are an excellent resource for practices that want to ensure claims are submitted in the correct format, as they are aware of the most recent billing regulations.

Precision Hub’s services help you reduce overall expenses and increase profits. The expertise of our team assists you in overcoming the obstacles associated with establishing a successful private practice. Our comprehensive and expert services enhance your practice’s medical billing process and efficiency—our service of medical billing for private practice aids in resolving the most significant billing-related issues.

Billing for Surgical Assistants: What you should know?

billing surgical assistants

If medical practices incorrectly bill for surgical assistants, they risk losing insurance money. A claim is frequently denied because a modifier was utilized incorrectly. Having a firm grasp of billing guidelines helps in minimizing the risk of financial losses.

This post covers every aspect of the surgical assistant billing process, including what a surgical assistant is, how to charge, how to get paid, and how to utilize modifiers effectively.

So, let’s explore everything about billing surgical assistants, from modifier usage to reimbursement.

Surgical Service Assistant

A healthcare provider other than a physician can assist with surgery, including:

  • Physician Assistants (PA)
  • Clinical Nurse Specialists (CNS)
  • Nurse Practitioners (NP)

Surgical service assistants include co-surgeons, team surgeons, and assistant-at-surgery.

An assistant-at-surgery physician provides hands-on assistance to the attending surgeon during an operation.

The operative note should clearly describe what the assisting surgeon did during the procedure for surgical assistants billing.

Billing Surgical Assistants

An assistant surgeon must be board-certified and licensed as a physician in the state where the services are performed. It is one of the prerequisites for billing surgical assistants. The primary surgeon will be compensated at the maximum allowable rate, 100% of the total payment for the primary surgery. If the criteria for assistant surgeon services are met, the assistant surgeon will be entitled to a 16% payment. A surgeon’s assistant may work in an entirely separate medical specialty or the same or a related field.

A physician may utilize modifiers 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when a qualified resident surgeon is not present) when invoicing for surgical assistant services. The modifier AS indicates that a non-physician performed the tasks of an assistant at surgery. When doctors want to disclose surgical help, they must provide the appropriate modifiers required for billing surgical assistants. Non-physician assistants who report surgical services are not permitted to use these modifiers in their documentation.

Modifiers for Surgical Assistants Billing

Modifiers for Surgical Assistants Billing

Below are the modifiers used for billing surgical assistants:

Modifier 80: Adding modifier 80 to the surgical procedure code indicates the services of a surgeon’s surgical assistant. This modifier refers to an assistant surgeon who assists the chief surgeon in every way. It should not be used by providers who are not physicians.

Modifier 81: Adding modifier 81 to the surgical procedure code makes it possible to find minimal surgical aid. This term refers to a surgeon who assists the primary surgeon during surgery but does not perform most of the work. It is more frequently utilized in private insurance billing than in Medicare billing.

Modifier 82: The modifier indicates the unavailability of a qualified resident surgeon during the service, and the service had to be performed in a teaching hospital. The medical record must explain why a resident surgeon was not present.

AS: It is used for billing surgical assistants when a non-physician (PA/CNS/NP) performs the duties of an assistant during surgery.

Co-Surgeon Billing Guidelines

Primary surgeons who are experts in many types of surgery and independently perform distinct components of an operation are compensated at a rate equal to 120% of the maximum payment for the primary procedure.

Here are the things you should know for surgical assistants billing when there are co-surgeons involved:

Applying the rules for multiple procedures is crucial if any operations are performed. In a separate operative report, each surgeon should detail their actions during the operation.

Both co-surgeons must utilize the same procedure code and add modifier 62 to their claims. The entire cost of the procedure will be divided between the three surgeons in an equal manner. Claims submitted by co-surgeons for surgeries identified as eligible for co-surgeons will be denied when both surgeons have the same specialty. When a non-surgical operation is billed with modifier 62 for a co-surgeon, the claim is refused because the co-surgeon concept does not apply.

Team Surgeon Billing Guidelines

Team surgery is an extremely complex treatment involving numerous doctors with various specializations and other highly qualified staff and equipment. No matter how much an operation is permitted to cost, the assistant surgeon is eligible for reimbursement of 16% of that total. If the conditions above are not followed, payment will not be issued for the services. Team surgery excludes unimportant operations, does not entail surgery, or does not require many doctors with diverse specializations, as well as other highly experienced individuals and equipment. Therefore, payers deny the claims for these operations submitted with modifier 66.

Reimbursement Rules for Billing Surgical Assistants

The co-surgeons each receive 120% of the surgery’s maximum payout. Typically, assistant surgeons are compensated at 16% of the highest sum paid for treatment. Each individual is considered when determining who will pay for the team’s surgical procedure. Upon establishing the medical need and appropriateness of assistant surgeon services, reimbursement for services performed by a PA, NP, or nurse midwife may be allowed. They must operate directly under the supervision of a physician to be compensated. The compensation for PA, NP, and nurse midwives is 13.6% of the maximum permissible sum for eligible operations.

See Also: How is Dermatology Medical Billing different from any other Medical Billing and Coding

Conclusion

This post shed light on important aspects of billing for surgical service assistants. It is important to note that inaccurately billing surgical assistants might result in a loss of insurance payment. So, it is imperative to have a firm grasp of billing guidelines for surgical assistants. An important aspect is the correct usage of modifiers based on the requirements. Modifiers including AS, 80, 81, and 82 are critical for billing surgical assistant services. A wise approach is outsourcing surgical assistant billing to proficient service providers such as Precision Hub (PH).

Precision Hub assists the medical industry with its billing and coding requirements. Our experts are here for you to make billing surgical assistants an easy task.

Email us at info@arturodigital.org if you have questions or need assistance with surgical billing.

What Is ERA in Medical Billing and How Beneficial It Is to Integrate ERA?

era in medical billing

ERA, or Electronic Remittance Advice, is a form of electronic communication that renders paper EOB (Explanation of Benefits) redundant. ERA in medical billing indicates if a claim was paid, its final status, and whether the payer made any adjustments to the amount billed.

Manually posting many EOBs or remittance forms requires a great deal of time and additional funds. Using paper archives to investigate and manage claims might lead to errors in recording payments. This method of operation is inefficient and results in significant administrative expenditures. Hence, ERA in medical billing is considered a beneficial and effective approach.

But what is an ERA in medical billing? Let’s explore in this post. This post intends to discuss various aspects of ERA. So, continue reading to learn everything about ERA.

What is an ERA in Medical Billing?

An ERA is an electronic form of EOBs that complies with HIPAA standards. Regarding medical billing, ERAs include information on a patient’s paid and denied medical claims, the due amount, and ultimate claim status. ERAs inform you of compulsory payments. ERA in medical billing maintains a record of patient information, including denied and approved claims, the final claim status, and any adjustments to the total amount owing. An ERA is completed electronically, requires significantly less time to complete and automate, and makes fewer or no errors.

Why your practice needs ERA?

Manually processing payments and securing patient accounts cost substantial time and money. Administrative duties and other non-clinical obligations take approximately five hours per week, equivalent to spending three weeks yearly on billing and insurance claims. Since different payers utilize different EOB forms and claim adjudication codes, manually posting and matching payments can take time and effort. In addition, manual processing of EOBs increases the likelihood of inaccurate data entry. If a team member types $30,000 instead of $300,000 by mistake, the entire batch must be examined to discover the problem.

EOBs’ slow processing and hefty administrative expenses exacerbate physical storage and document discovery challenges. Even worse, you lose the chance to benefit from big data’s power. Without an accessible and well-organized data warehouse, providers cannot precisely analyze their payments and denials to make better business decisions.

If you combine ERA in medical billing with a robust analytics solution, your practice can identify underpaid claims and increase its efforts to collect the money. Examining refused claims will boost first-pass resolution rates, increase collection efforts, and reduce future claim denials. All of these will contribute to the monetary stability of your practice.

ERA: Medical Billing Usage

ERA in medical billing is essential to confirm the information about claim submissions and denials. It provides important information about the payment schedules. Additional information about co-payment, deductibles, and co-insurance can be obtained through ERA. It helps in keeping track of reimbursement collection.

Benefits of ERA in Medical Billing

Benefits of ERA in Medical Billing

The advantages of ERA for medical billing include shorter payment timeframes and the release of administrative personnel to work on other initiatives. ERA can assist with medical billing in numerous ways, such as:

  • Save Time

Manual procedures demand great time and effort due to the enormous number of claims processed by the medical industry. Electronic transmission and production of ERAs accelerate the procedure significantly. Therefore, your front-office workers will have more time to interact with patients and complete other duties.

  • Reduce Errors

When manually processing a large volume of EOBs, it is probable to enter inaccurate dollar amounts, which can cause problems for you, your patients, and your payers. Using ERA software minimizes the possibility that this will occur. When an ERA medical billing model is utilized, the occurrence of these errors is drastically reduced. The final result is a more accurate collection of funds.

  • Facilitate Communication

If you use EOBs, you must provide your patients with information on billing and payment following each visit. Since ERA medical billing is based on digital technology, it is possible to include all of a patient’s claims in a single communication. This grouping makes it easier and faster to collect payments from patients, as each patient’s bill is maintained in a single spot.

  • Efficient Denial Management

ERA medical billing can include acceptances and denials, which is a substantial improvement. Regarding ERAs, focusing on denied claims generates revenue more rapidly.

  • Reporting and Analysis

Since ERA platforms are online, they usually contain reporting and analysis capabilities. Using these tools, you may determine how well or poorly your practice receives patient payments. Utilizing these indicators will improve the performance of your business.

  • Quicker Collection

EOBs make it difficult to know if a patient has viewed and responded to your bill. However, ERAs are straightforward to track. This facilitates communication with patients whose payments are past due and expedites the payment process.

See Also: Advance Radiology Medical Billing Guide

Conclusion

ERA in medical billing significantly impacts the correctness of payments, the practice’s efficiency, and the payment collection rate. By sorting ERAs, you can improve collection efforts, reduce the number of denials, make your staff more efficient, and save money on labor and paper; when claims are submitted electronically, both the frequency of errors and the number of claims that are denied decrease.

Precision Hub has complete control over the ERA channels and eligibility setups. If you do not use ERA and auto-posting, you miss out on an opportunity to streamline your revenue cycle. Moving to electronic payment methods and automating the payment posting procedure can decrease your workload while still receiving prompt payment.

You can call us at (888) 454-4325 for additional information about ERA in medical billing. You can also book your free demo with us.

How Fake Medical Bill Scams Are Affecting the Healthcare Industry

fake medical bill

Scams and fake medical bills have been an issue in the medical sector for centuries. Hospitals, doctors, and those who process the bills (insurance companies) have had no easy method to halt them or make them less likely to occur. The healthcare business needs a quick method to prevent the payment of fake medical bills and the acceptance of bogus claims.

Fake medical bill scams, which affect both individuals and businesses, directly cause losses in billions of dollars. It could increase health insurance costs, put the patients at risk for medical procedures they do not need, and make them pay more taxes.

This article aims to shed light on fake medical bill scams. The post highlights some of the most common scams related to fake medical receipts and bills. Continue reading to find out how fake medical bills affect the healthcare industry.

Fake Medical Bill Scams

Currently, the health care system administers the procedure manually, which is time-consuming, costly, error-prone, and labor-intensive. The US medical business loses millions of dollars annually due to fraudulent schemes or fake medical bill scams.

A considerable percentage of healthcare fraud is committed against Medicare and Medicaid, which are government-run and tax-funded health insurance programs. Due to their small size, they are easy to capture. Around 1% of Medicare claims are audited. Medicare, however, can process up to 4.5 million claims each day. These projects are in peril due to insufficient funding. There are not enough employees to monitor everything constantly. This enables the submission and payment of bogus claims or fake medical bills.

Common Frauds Involving Fake Medical Bills

Various incidences of medical fraud with fake medical receipts have been reported. For instance, healthcare fraud involving pharmacies has risen in the past five years. Pharmacists are billing Medicare for more expensive medications. Similarly, other areas are also involved in fraudulent activities. Even ambulances and their personnel have committed fraud. By telling the patients that they cannot walk, they fake the need for getting ambulance service. In this manner, the ambulance business bills Medicare $400 for every emergency pick-up.

Some of the common medical frauds are discussed below:

  • Upcoding

Imagine that a patient visits the hospital for a sprained ankle and receives care, but the hospital bills the patient’s insurance company for a fractured ankle. This issue is referred to as “upcoding.” The physician must supply the CPT code list with each claim as proof that each treatment and therapy was performed. These codes indicate how lengthy or short the bill for the therapy should be. Most insurance companies use computers and receive numerous hospital and provider invoices daily; they frequently overlook minor coding errors. Since these companies must make various types of payments, they frequently overlook these kinds of errors or fake medical bills.

A recent case of a fake medical bill involves two individuals convicted guilty of health care fraud in a $1.4 billion scheme involving rural hospitals in Florida. Jorge Perez and Ricardo Perez, both of Miami, Florida, collaborated to illegally bill for approximately $1.4 billion in laboratory testing services that were not medically necessary. They exploited rural hospitals as billing shells to submit claims for services performed mostly at laboratories outside rural hospitals.

  • Phantom Billing

Invoicing for services that were never performed is one of the most common forms of billing fraud. This type of fake medical bill scam increases the cost of health care because the charges are unjustified, but it also costs millions of dollars annually to detect, prevent, and track this fraud. These claims affect the federal budget, policy, and a patient’s total health insurance liability. Financial claims reveal the services rendered to patients and can influence their future care.

In an incident of phantom billing reported in Newark, Benjamin Sabido pleaded guilty to healthcare fraud in federal court. He obtained $237,182 fraudulently from December 2006 to April 2010. He instructed employees to submit fake physical therapy bills. He compelled unqualified personnel to administer physical treatment, such as electrical stimulation, massage, and other services. He did not employ any licensed physical therapists or other trained professionals. The physician was sentenced to 10 years in prison, along with a fine of $250,000.

  • Inflated Bills

One sort of overcharging is sending inflated medical bills to insurance companies to overcharge them for treatment. Linda Burdick, chief assistant state attorney, stated that she underwent back surgery and that her insurance company gave her an excessively high bill for $60,000. She requested assistance from financial investigators, who determined that the charge was excessive for items such as six surgical screws, which cost $1,750 each. Everyone who receives hospital care must review their bills for errors such as overcharging and double billing.

  • Service Unbundling

This fraud occurs when a hospital invoices separately for various procedures that should have been billed as a package. Due to this independent billing method, the charges appear extremely high. Unbundling is a sort of up-coding. These fraudulently high billing practices target Medicaid and Medicare patients because they provide discounted bundle packages for typical operations like lab tests and scans. Providers and healthcare professionals bill individually for these packages and the package fees are deducted to increase profits illegally.

  • Self-referrals

Self-referral is a practice that needs an awareness of its illegality. Self-referral is when a physician or other medical practitioner recommends themselves for a surgery or procedure that a patient requires to get compensated. Self-referral is prohibited because unnecessary treatments waste money and effort.

Reporting Frauds

A significant portion of the medical business is self-regulated, which is positive. If a physician suspects that a provider, another physician, or a hospital is committing fraud, they must inform the appropriate authorities. In addition, if they observe something that poses an urgent threat to a patient, they can inform the state licensing authority or the medical community to take quick action.

Even if a patient believes that the healthcare provider is engaging in unethical or illegal conduct, they can file a complaint so that either the quality of healthcare can be improved or the clutter that led to believe the process in the first place can be removed. Notifying the state’s health department about fake medical bill scams or frauds is crucial.

See Also: Protect Yourself From Surprise Medical Bills

Conclusion

Fake medical bill scams could increase health insurance premiums, the likelihood of unnecessary medical procedures, and the tax burden. Purposefully deceiving the healthcare system to obtain illicit benefits or payments is a healthcare fraud that needs to be reported to the concerned authority.

Contact Precision Hub if you want to maintain accurate medical billing. We are experts who will streamline the billing process for your practice while remaining compliant with HIPAA regulations. Call us right now, and we will help you out. (888) 454-4325