Billing Practices That Can Be Costly Part II

In part II of this article we will further discuss costly medical billing practices. In some cases, these have led to the loss of medical licenses for false reports include billing unnecessary services, double billing, upcoding or altering CPT codes, unbundling and false diagnoses. 

Unbundling is when you charge separately for a visit or a procedure that is normally part of another procedure or visit.  Double billing is when you bill for the same procedure multiple times on different dates. 

Upcoding refers to using a higher procedural code than what was performed.This includes billing for services that the patient did not receive or using codes that are at a higher level of what really took place during the visit or procedure.  Some examples of that are where a practice submitted bills for office visits for established patients on days where the office was closed, where the physician was not in the office or on vacation and on holidays and weekends when the office is closed. 

Another example is when a physician billed for office visits for parents and siblings when one child was brought into the office for a visit.  The parent had never been seen before but the physician used all the information provided for the insurance where the parent was the subscriber of the health plan, so it was easy to gain access to bill under the parent as well as the child.

Some health care providers advertise “free” services.  When the patient arrives it appears to be a “free” service but ends up being charged for the office visit and other procedural codes.

Other costly practices include failure to produce or complete medical records, which are required to back up billing codes, delegating treatment to individuals that are not qualified or it is not in their scope of practice, and performing procedures and tests that are not with valid consent from the patient.

Billing fraud leads to higher premium assessments by the insurance companies.  HIPAA prohibits billing for medical services “that a person knows or should know are not medically necessary.”  Also violating HIPAA laws and guidelines can result in monetary penalties up to $10,000 and an additional cost of 3 times the dollar amount for each claim.  These crimes are also punishable by up to 10 years in prison or even life in prison if a patient dies as a result of fraudulent activity.

Billing fraud is costly for all those involved, the practice, the doctor and their license and more importantly the patient.  Fortunately, most health care providers are honest and dedicated to helping and providing the best care for their patients and only want what’s best for them and their medical practice.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Billing Practices That Can Be Costly – Part I

Obviously, to receive proper reimbursement it is very important to have accurate coding practices for all health care practitioners however; here are several reasons.  A group that is often involved in the billing process is nurse practitioners. Generally they are billing for their own services or they may be using a billing form (superbill) provided by their employer by marking procedural codes and diagnostic codes in order to bill for their services.  The responsibility for the accuracy of the coding and billing, as well as for maintaining medical records that support the diagnosis code and procedural code that is being used to bill for specific services, is the professional provider or the nurse practitioner. 

Keeping up to date with accurate coding procedures is very important when billing to receive maximum reimbursement.  However, due to new codes being added, modified or deleted, this may cause an impact on reimbursement.  Sometimes the definition of a code may not be so clear.  That’s why it is vital to utilize sources that are available to the medical community.  Such as workshops, online information and online telephone consultation services for health care providers to get better clarification on a code before billing.

It’s also important to remember that even if billing by the physician or nurse practitioner is outsourced to an outside billing service or a trained billing clerk that is onsite, it is the person on whose professional licensure the care and billing are based is the person that is responsible for accurate billing.  A nurse practitioner or a physician still has to learn something about reimbursement and coding.

Any health care professional who knowingly cheats on coding to enhance their reimbursement, can be guilty of both civil wrongs which is considered a “breach” of the insurance contract, and it’s considered a crime, which can lead to costly legal fees.  Billing fraud can also result in having to return part or all of the wrongly paid money, fines, loss of their professional license and possibly serving time in prison.

How do fraudulent claims get noticed?  There are several ways.  Some insurance carriers have fraud detection software which they use to analyze data.  When unusual billing patterns are discovered, they initiate an investigation.  Sometimes it is the patient that is complaining about the amount of the bill or services that were billed.  Employees have revealed on their good conscience of fraudulent practices and don’t want to be part of the scheme or it violates their own ethics.  Bottom line is physicians or other health care providers who engage in this type of behavior have been costly and have led to them no longer being able to practice in the medical field.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

“Like” us on Facebook at