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How to report medical billing fraud

report medical billing fraud

For medical billers, ending up in a fraudulent billing situation can have serious repercussions. Those in the billing industry work hard to meet a high standard and complete an efficient, clean billing process every day. While some billers and patients purposefully submit incorrect claims and information to try to get more money or save money, many times something that appears as medical billing fraud is actually just an accident. In these cases, it’s important to carefully go through the processes of recognizing where things went wrong, discuss it with all involved parties, and come to an agreement that makes everyone happy. We broke down some of the things both billers and patients in this situation can do to quickly and efficiently solve the issue. 

Work directly with everyone involved

The best thing you can do when faced with a potential fraudulent situation is to get everyone involved to piece together what happened. If you work at a doctor’s office, or you were the patient receiving care through the doctor’s office, it’s important to contact the people you worked with and explain the problem. If you don’t get everyone involved from the start, you’ll likely run into trouble and miss out on valuable information needed to correct the bill. 

Reach out to the company’s CFO

You may feel uncomfortable getting the billing company’s CFO involved early on, but billing fraud is no joke, so the more help, the better. Explain that you simply want to solve things as quickly and as accurately as possible. Billers don’t want a bad billing experience attached to their reputation, and patients just want their billing sorted out—both parties want a simple solution, and that’s exactly what they get when all parties cooperate. 

Work with a medical billing advocate

If you don’t have any luck working with internal billers to rectify the problem, it’s worth teaming up with a medical billing advocate. Billing advocates are people who work professionally to determine whether or not a person has been fraudulently billed, and then help them fight the issue. If you aren’t comfortable confronting the practice at the beginning of the process, or if you don’t feel like you have the time or knowledge to become heavily involved with the issue, hiring a billing advocate is a great way to efficiently find a solution. 

Contact your state’s Department of Health

You may or may not get to this step of the process, but if your hospital or doctor’s office is refusing to alter the bill and you’re confident that it’s incorrect, it’s time to contact your state’s Department of Health. Once you pass this information along to your local DOH, they will investigate the claim and figure out whether or not the bill was actually fraudulent. 

Report the fraudulent bill to your insurance company 

Whether some or all of your bill is covered by an insurance company, it’s important to alert them of the possible fraud. When your insurance company is aware of the problem, they’ll reach out to the doctor’s office or hospital themselves to see what they can find out about the situation. Your insurance company will be as concerned, if not more concerned, as you are about the potential fraud, since it puts them in a position of losing money, too. Whether you’re working with private insurance or Medicare, you should have access to a number to directly contact the company and have a productive conversation. 

How medical billers can prevent fraud at their practice

Most medical billers want nothing to do with a fraudulent billing case, so it’s important to run the business in a way that prevents such scams from happening. If a biller purposely tries to charge a patient more or less for a service, that’s illegal and a completely different story. However, assuming most incorrect claims are submitted unintentionally, there are ways to decrease the likelihood of this happening at your practice. We highlighted a few of them below. 

Find reliable medical billing software

If you don’t already have web-based billing software at your company, you need to change that. Not only does medical billing software save you time and money, it also reduces the amount of billing errors you submit. Since billing errors could potentially serve as the grounds for a fraudulent billing claim, having modern software on your side is a great way to decrease the chance of this happening under your nose. 

Conduct frequent training sessions 

The best way to keep your billers on top of the latest trends and industry rules is by hosting regular trainings for your team. This might be every month, or it might be every few weeks—the important thing is that you figure out what works for your business. These sessions will give your team a chance to ask questions, collaborate, and share any experiences that will help the team grow together. 

Hire experienced billers

It’s not always easy finding experts to hire at your business, but it’s definitely worth the time. If you truly want to run a successful billing operation, you need to hire a talented, motivated staff. Once you have the right people at your business, there’s no limit to what you can achieve. So, decide what type of employees you want at your business, figure out how to recruit them, and watch your business thrive. 

See how billing software can change your business today

The best medical billing software in the game can change your business. It can improve your clean claim rate, help you avoid billing fraud scandals, allow you to bill claims faster than ever, and get reimbursements into your pocket in just weeks. The question is, why are you still billing manually? Finding the right solution can be difficult—we get that—so we’re here to make it easier on you. At Claimgenix, we offer a free demo of our billing platform to anyone interested! Whether you’re billing Medicaid, CVS Health, Kaiser, or another insurance company, Claimgenix has you covered with the ability to bill over 8,000 different payers. Sound like a good deal? We think so too. Get in touch with our experts today to schedule your demo and see what Claimgenix is all about.

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