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

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Ways to Collect Deductibles at the Beginning of a New Calendar Year

It’s that time of year again when patients deductibles are needed to be met.  EOB’s are being received with no check and a large portion or all of the amount billed is going towards a patients deductible.  Then from that point, a patient invoice is sent out and it’s up to the patient and it’s their responsibility to pay the physician.  With that in mind, how can practices keep the cash flow going during the first few months of a new calendar year?  Most offices have taken a proactive approach with patients that have deductibles.

 Here are a few tips on ways to keep a steady cash flow during this time.

 (1)  Take the appointment schedule for the week or even each day and go through all returning patients and call the insurance company to verify how much of the deductible has been met. 

 (2) Start a separate list with the patients name and insurance and how much of the deductible has been met and what the deductible amount is.

 (3)  When making appointments, ask the patient if they have a deductible and if they say they do, then it would be wise to inform them that a portion will be collected at the time of service.

 (4)  Decide up front how much your office is going to collect, some offices collect between 20% to 30% of the total bill. 

 (5)  Make sure to indicate on the superbill for the insurance biller that the amount collected is for that days visit.  Otherwise the patient may have an outstanding account and you don’t want to confuse what date of service it should be applied to.

 (6)  Patients with Medicare may also have a deductible but if they have a secondary insurance, that insurance will usually pick up the secondary balance such as Medi-cal.

 Most patients know that they have a deductible and should not be surprised that they are responsible for that portion before their insurance starts to pay.  It’s best to be as tactful as possible when asking the patient that they are expected to pay up front when a lot of times the patient is ill and it may seem uncomfortable asking for payment under those circumstances but it is not unreasonable. 

 Even though this may be very time consuming for the office to handle, it really makes a difference during this time of year when you would normally be receiving payment from the insurance company but many offices have implemented this policy and have seen a big difference in their cash flow.  The office will truly benefit and it’s also a way to keep your patient portion accounts receivable lower.