Defence Auditing Services


Medlinks Cost & Containment — Defense Auditing

Just like any other organization, health care facilities have boards that want assurance that their facilities are working properly, money is being spent appropriately, and that all of the controls in place are actually working. Traditionally, healthcare auditing services provided assurance around payroll, financial areas, purchasing, and more; but now it has been developed by people with personal interests and passions. Internal audits are happening in lots of different ways and the scope has varied enormously. We see healthcare defense auditing services as a natural evolution of internal audit, using a more rigorous and systematic approach. How often these audits shall be performed depends on the practice, size, complexity, and billing practices of a medical facility.

Defense Auditing focuses on being proactive and avoiding mistakes and frauds

Defense auditing in the healthcare sector works in a range of ways but it mainly focuses on being proactive and avoiding mistakes and frauds, which can lead to compliance issues and unnecessary expenses. According to the US Department of Health and Human Services Office of the Inspector General (HHS-OIG); fraud, waste, and abuse cost medical facilities nearly sixty to seventy billion dollars each year. A significant contribution to this comes from two main causes of health care fraud — upcoding and overbilling. Once detected, whether intentional or unintentional, these mistakes can put the defaulter in serious troubles —can lead to heavy penalties and even criminal prosecution.

Circumstances under which upcoding and overbilling happens

Upcoding and overbilling occur in various situations, all of which start mainly due to oversight and negligence. Inaccurate coding is the number one reason for upcoding. It can also occur when you code for treatments that were not medically necessary for the patient. Double billing is one of the most common reasons behind overbilling occurs. When you just inflate the overall amount your payer organization owes you on a bill, you are basically doing overbilling. Another major reason behind overbilling is unbundling or fragmenting billing codes. This typically happens when a coder wrongly increases a healthcare provider’s profits by separately billing bundled procedures, resulting in higher reimbursement.

Steps healthcare organizations can take to prevent upcoding and overbilling errors

Coding for higher items or services than what was actually performed is considered illegal. For example, coding for initial inpatient consultation, with a higher-level and M code, after performing a follow-up inpatient consultation, is considered a fraud and should be avoided. Also, due care must be taken to not code for services that were not medically necessary for the patient. Another common misuse is billing separately for services already included in a global fee. Billing for an E&M service the day after surgery, when the follow-up is already included in the global surgical scene, is a no-no. Billing for services at such low quality that they are virtually worthless and services that are not rendered should be avoided. Inappropriate use of modifier codes is a common mistake and must be prevented. Do not claim payment for an E&M service when care rendered is not significant, separately identifiable, or not above and beyond the care usually associated with a procedure performed.

Specialists in the area can help minimize risks

Hiring a medical coding and billing company is one of the most effective ways to address all the above-mentioned challenges. It prevents the risk of internal staff making errors and mistakes and ensures that the process is carried out by professionals in the area who are always up to date. Apart from protecting your business from these compliance-related issues, a suitable outsourcing partner also helps you maximize your reimbursements by properly guiding towards best practices.

Medlinks Cost Containment can help you avoid mistakes, stay compliant and maintain productivity

Even after taking necessary safeguards, coding and billing mistakes, do occur. Performing regular healthcare investigation and defense audits are some of the best practices to address these issues. Medlinks Cost Containment can help you avoid mistakes, stay compliant, and maintain productivity. During the audit, we reconcile the services rendered on the patient’s chart with the services coded on the payment claim to make sure they match in every case. We have the best practices you can follow to maximize profitability without inviting the risks involved in upcoding and overbilling.

How is your medical billing benchmark today as compared to industry best practices? Are you aware of the costly mistakes that might be putting your business at risk? Call professionals at Medlinks Cost Containment for a comprehensive audit of your practices!

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