Medical Billing Services

The incidence of fraud and abuse is evenly distributed across the spectrum of health insurance, and it is most intense in Medicare. In an industry characterized by the highest professional ethics and integrity levels, it is strange but true that health insurance fraud and abuse have reached alarming heights. Even worse, 80 percent of healthcare fraud is committed by hospitals, clinics, and healthcare providers themselves. In fact, according to a reliable survey (by the American Society of Business and Behavioral Sciences), the cost of such Fraud and abuse under Medicare is a staggering $ 700 billion per year, which is about a third of total healthcare costs. Although the federal government created a cost recovery mechanism, the level of reimbursement for reduced Medicare costs was rather bleak, with approximately 5% of Medicare fraud and abuse reimbursed annually.

While the federal government has a strict policy of punishing lousy faith, the duality of threat – in which beneficiaries and suppliers alike promote Fraud and abuse – and an unholy relationship between them – collude to obtain dishonest gains – instead, they have more challenging tasks.

While unscrupulous hands have won, Medicare has to bear the brunt: the Sustainable Growth Rate (SGR) has become so monstrous that the federal government is about to cut Medicare payment. To make matters worse, the mandatory transition from ICD-9 to ICD 10 could make Medicare even more susceptible to fraud and abuse. The number of diagnostic codes increases from 14,000 to 69,000 and treatment codes from 3,800 to 72,000, and there is a latent trend that the more complex the coding system, the more likely it is to be fraudulent and abused.

Duplexity of Fraud and abuse of health insurance plans, Fraud by health care providers, Fraud by beneficiaries of health insurance.

  • Using a member ID that does not belong to this person
  • Billing for services that were not provided
  • Re-submitting a claim for the same service
  • Distortion of the service provided
  • Do not remove someone from the policy when that person is no longer eligible
  • Add someone to the procedure which is not suitable for coverage
  • Doctor Shopping – Visit multiple doctors for multiple prescriptions
  • Upcoding: charging for a service that is more complex or expensive than what was provided

The high cost of appointing remediation audit contractors (RACs), accounting for nearly a quarter of the total reimbursement to be audited for Fraud, is also not helping the case. With no other alternative, Medicare has put in place drastic measures to identify, investigate, prevent, handle, and recover from fraud and abuse by service providers, members, groups, brokers, and others. While RAC audits have been able to recover a significant amount of fraudulent claims, they still find ways to slip right under their nose in many cases. Thus, the suspension and revocation of the license to practice and the benefits of Medicare, the prosecution have become more viable options., with its long-standing as the leading medical billing consortium in Medicare-related Reimbursement and Revenue Cycle Management services, may well be your preferred partner as it is immune to legal consequences of Fraud under Medicare abuse. Since Medicare fraud and abuse can lure beneficiaries and providers into legal ties, it is time for them to carefully avoid these sinful habits or seek professional advice if they do not intend to do so. This is where the competence of a medical biller and coder will come to the fore to help them practice honest medical billing practices.


So, when you are focusing to care for your patients, let us manage all your back-office operations and help you improve your clinic’s financial health and turn it into a successful business venture.

By Caitlyn

Leave a Reply

Your email address will not be published. Required fields are marked *