How To Identify And Report Medical Billing Fraud

For many people, leaving the hospital with a clean bill of health doesn’t mean the end of their worries. After a successful operation or undergoing emergency treatment, patients next face the immense task of making sense of their medical billing. So, it’s not surprising that many can only shake their heads in disbelief when they see how much they need to pay for their hospital stay or doctor’s visit.

With the ever-rising cost of healthcare, it’s prudent for everyone to scrutinize their medical bill. It would be best to ascertain that each penny of your hard-earned money that goes into your healthcare bill is accurate. If you find minor mistakes here and there that are accidental errors, they should not be a cause of concern. Medical admin staff can make mistakes, and such instances are more common than you think. 

However, it’s a different story if you find glaring errors and huge discrepancies on your bill. When billing errors are significant, you may want to look more into them because you could be a victim of a targeted healthcare fraud scheme.

Here are ways to identify and report medical billing fraud:

1. Scrutinize Each Item In Your Bill

You won’t identify errors if you don’t check all the items in your bill. If you have insurance, check your explanations of benefits (EOB). It’s a statement that shows which portion of the medical bill is paid by your insurance and which part you still need to settle. In an EOB, the insurer discloses each item and describes it in detail, so it will be easier for you to identify suspicious charges if you need to report fraud or seek punitive damages against your healthcare provider.

Some of the things that you should be on the lookout for include:

• Getting billed twice for a similar service
• Upcoding to a more complex or costly procedure than what you received 
• Getting billed for a service you did not get
• Unbundling one procedure so scammers can bill it in multiple separate parts

2. Compare Billing Items With Your Notes

Some fraud schemes involve charging additional unrendered services. Thus, it helps to keep notes to avoid surprise medical bills. You can compare what you have in your notes with the items listed in the billing. 

Aside from details about your condition or prescription meds, there are other things you may also want to include in your notes. Make sure to put in your dates of visits, the name of the attending physician, and any service you received, including tests, procedures, and immunization, among other things.

3. Contact And Coordinate With The Billing Office

Hospital billing errors happen all the time. Reports say that almost 80% of hospital medical bills contain mistakes. So, when you find some charge discrepancies, don’t hesitate to call on the hospital billing department to air your concerns.

4. Report To The Right Channels

Often, you can negotiate and settle issues with the provider, especially if the billing mistake is a one-off error. But there may be some instances where your healthcare provider cannot resolve the errors and discrepancies. If you have ongoing therapy, you may also notice recurring errors or patterns of unbundling schemes. Under such circumstances, you may probably have uncovered medical billing fraud, which is a serious felony.

Since fraud is a severe crime, it’s always prudent to report one after you have tried your best to settle things with the healthcare provider or you’re confident that there are indications of deception. Once you report this crime, you will need to cooperate with authorities and provide proof.

You can start by determining who pays your medical bill. Aside from you, will a significant portion be settled by your private insurance, or will either Medicare or Medicaid foot the bill? 

If it’s your private insurance, you may report your case to the company’s fraud division. Since insurance companies typically pay for the bulk of your medical expenses, they would be very interested in investigating your complaint. They surely want to know if the healthcare staff or doctor is responsible for the potential fraud and how long it has been going on.

Even if you are not the one paying for your bill, you still have the responsibility to report a healthcare scam. If you’re 65 years old and above and using Medicare, you can report suspected fraud to the U.S. Inspector General’s Department of Health and Human Services Office. But if you are using Medicaid, which the state typically funds, you can report the possible abuse to your state’s attorney general’s office or the health and human services department.

5. Don’t Be Afraid To Ask For Help

If you’re unsure about your findings or don’t know what to do if you see billing schemes, you may seek professional help. To aid in auditing and to understand your billing statement, you may seek the help of an accountant, specifically one who specializes in auditing. They would quickly recognize a case of suspected fraud when they see one, and they could also assist you in gathering proof.

Additionally, you could get the help of an attorney, especially if you’re interested in seeking punitive damages and other claims. You may want to look for a reputable lawyer with solid experience in similar cases to help you out.

The Bottom Line

Mistakes in hospital bills happen all the time. It’s best to take time to check your statement and ascertain the items are accurate. However, if you believe you’ve identified a healthcare fraud and the errors in your medical billing are recurring or are part of a blatant scam, you ought to report it immediately. Consult with a lawyer to know your rights and claims as a result of medical billing fraud.