Unfortunately, injuries and hospitalization come with the unwelcome prospect of medical bills, especially if there is a lawsuit accompanying the injury and it is necessary to argue for damages.
The healthcare field is comprised of many different moving pieces, all of which need to work together for treatment to happen, insurance to be billed, and documentation of care to be provided to support procedures. Codes are used by medical professionals to indicate to healthcare insurance companies the type of care that was provided to patients.
But what happens when something goes wrong? Everyone is human and we all make mistakes. So, what are the most common mistakes to watch out for?
The 4 most common medical billing errors are Upcoding, Unbundling, Erroneous charges, and Duplicate Charges, and each one of these 4 most common medical billing errors affects the overall billing in a different way. Let’s talk about each.
Upcoding happens when a code for a more expensive treatment than the one that was provided is reported to the insurance company. This can occur as an honest error, but there are hospitals and other providers who have been caught doing this deliberately. It is illegal, and it is a fraud.
Examples of upcoding can include a sedative treatment being billed as anesthesia, or a procedure that was carried out by a nurse or an assistant being billed as if it were performed by a more senior doctor.
A review of the codes in your medical bills will likely be necessary to determine what is fair and reasonable in a case where the injury is involved. One of the first things you should do is check to make sure that the statement of treatment that you receive on your Explanation of Benefits matches up with the care that you remember receiving.
Unbundling is another type of improper coding that is also referred to as “fragmentation.” Certain providers, particularly Medicare and Medicaid will reimburse procedures at a lower cost if they are typically performed together. One example of this is incisions and closures that are incidental to surgeries.
Fraudulent billing of these charges occurs when they are “unbundled” or when multiple codes are used to bill portions of a procedure separately. It is fraudulent because ordinarily, the procedures would be together, and the healthcare provider can charge a higher rate.
Unfortunately, unlike Upcoding, which can often be an error when someone enters a code for a procedure that is similar to the one that is performed, Unbundling is more likely to be a deliberate cheat of the system. It is an effort to inflate the cost of the care provided to patients, which in turn results in the provider receiving a larger payout from the insurance companies. Unbundling may be harder for the average person to see because he or she might not think to check if the incision and closure are listed as separate items.
3. Erroneous Billing
This happens when the wrong code is entered entirely and maybe the easiest for the patient to spot upon reviewing their Explanation of Benefits. One of the reasons that an Explanation of Benefits usually says “this is not a bill” is because it is a breakdown of the services offered so that the patient can review a description of their care.
This, along with the next of the 4 most common medical billing errors is highly likely to be an accident. There are so many codes in the medical system that entering a few numbers out of order can entirely change the type of service reported, and it does not necessarily point to some sort of fraud.
4. Duplicate Billing
Duplicate billing is exactly what it sounds like when the same code is entered more than once for the same treatment or procedure.
This may be more difficult if a patient is trying to look for it in their Explanation of Benefits because often the services listed are simply funneled under catch-all terms such as “Laboratory Services” or “Prescription Drugs” and without having a professional review the codes that were reported to insurance, it may be difficult to identify if more than one laboratory service was performed, or if the same one was a duplicate billing.
Duplicate billing is one of the 4 most common medical billing errors likely to simply be a mistake, where someone entered the same code twice without realizing it. Yet, it is still important to ensure an accurate representation of the treatment rendered so that the patient and the insurance company pay what is appropriate for the care.
If it is necessary to argue for damages regarding past medical bills or make a case for the cost of future medical care, then having a professional who is used to reviewing these codes can be critical to success.
Why You Need Medical Billing Analysts
It is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.
Whether you are a plaintiff or a defendant in a case, one of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.
Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.
The team of MBA professionals will review the hospital, medical, and therapy bills to determine the value of past medical expenses. Based on local CPT codes, they can also perform a Cost Projection Analysis of future costs. Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.
Contact Medical Billing Analysts by phone or email at 800-292-1919 or firstname.lastname@example.org. We’re here for you, whether you need an evaluation of a single charge or a complex injury case.