Medical Billing Fraud and Abuse... How to Stop It.

Medical Billing Fraud and Abuse... How to Stop It. Hospital and Doctor fraud and abuse accounts for 3-10% of all healthcare spending.

This means, a company with 1,000 employees is spending $300K- $1M per year as a result of fraud and abusive billing practices.

Doctor and Hospital may engage in 'Upcoding' to maximize reimbursement. They do not view changing codes to maximize reimbursement as 'Upcoding,' but there is a fine line between correctly coding and 'Upcoding.'

Insurance companies often deny claims and require prior authorization. However, these practices do not stop fraud and abuse. Often the denials and prior authorizations miss the fraudulent claims and abusive billing practices.

Solutions include: 1) Become Self-Funded and review your own claims, 2) Move away from Fee-for-Service to non-claims-based healthcare services such as an on-site or near-site clinic or direct contracting.

Sources:

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[unebonnevie]

One time a doctor's office person charged me $200 for referring to a specialist, basically charged me $200 just to give me a name of another doctor. I have a feeling she had done that before, because most people simply pay blindly. I told her that's fraud and illegal, and they took off the charge. Other horrible frauds include charging a $50 bill fee to send the patient a bill and charging extra if you have a walk-in service at a clinic on the weekend!

The USA's health care is run by greedy, immoral business people that really need to be jailed!

[unebonnevie]

This video and the last three you made, Dr. Bricker, are excellent in terms of healthcare frauds. Sometimes frauds go both way, the insurers deny coverages blindly. Thank you for all your informative videos on healthcare. Please keep up the great work! More people will find out of your vids.

[TheMagpieOfficial]

I always pay my medical bills when they come in the mail using my HSA. I keep the paper receipts too. But my OBGYN office has a habit of calling with unpaid bills from years ago. I have to take time out to look for them and prove they were paid. When I prove, she always comes back with yet another bill… rinse and repeat. I’m starting to suspect the billing department which is in office is over billing.

[mascaretllcmanager]

As a medicare enrolled with excellent supplement coverage, I feel I 've been targeted for excess billing and balance billing.
Had a new PCP bill for advanced directive planning services ( asked me if I had a living will (answered yes), then said 'we should have a copy'.... and charged 100. for that service. ????What, no you do not need a copy as I will not longer receive care here. At the same visit, the inexperienced staff took blood with a butterfly ( so unnecessary as I have sewer pipes for veins) which medicare will not pay for so they are charge me. I DO NOT have some bad replacement policy, I. have a G and supplement and feel I've been scammed.
Forget the US, Medicare and the whole billing mess with consultants trying to maximize coding...I'm going to another country where people know how to provide care and not just bill.

[tsetendorjee]

Thank you Dr. Bricker !!! We love your YouTube !!!

[williampennjr.]

The aren't allowed to bill for follow up visits, so they get around it by scheduling you with a different doctor.
What I don't get is why insurance company's let them get away with it. Why does Cigna approve a $750 charge for a 10 minute conversation with a doctor that provide no information about your health?
People need to read the patient bill of rights. You have the right to an itemized bill with explanation of all charges.

[mylesc]

Can you please help me? I went to the ER without insurance, because Urgent Care wasn't open yet, due to it being early in the morning. I got a cut on my face, and I couldn't stop the bleeding. I went to the ER. I spoke to the admissions person and they asked me about my insurance. I told them that I didn't have any, because I was recently laid off. The admissions person gave me an application for AHCCCS, which is medicaid for the State of Arizona. I filled it out and gave it to her while I was waiting to be seen by a doctor. There was only one person in the ER waiting to be seen. I waited two hours before I was finally able to be seen by a doctor. By that time, the bleeding had stopped. The doctor looked at my wound, and put a band aid on it. I was released from the hospital. I got a bill from my local hospital for $801. I called the hospital and they told me that they don't show anything in their records of me applying for AHCCCS. I called the State, and they told me that they never received an application from the hospital for me. Today, I got another bill for the same visit from the doctor that so called, "treated me". This bill is for $ 518. The bill includes a $408 level 2 emergency department visit, and $110 for a visit between 10p-8a., equaling $518. This bill is in addition to the $801 bill that I received from the hospital itself. My grand total for one band aid is $1319.
If you could help me out all, I would greatly appreciate it! Thank you.

[Brainjoy]

I'm dealing with a case manager who is reporting she is meeting with me when she is not, and billing my medi-cal, and probably other clients on medicare. Her boss does not care.

[kateskeys]

I do not trust, respect or even LIKE ANY of my doctors. I’m sure Medicaid feels the same way. Or they should.

[marisarivers]

I worked for a billing company that happened to bill Medicaid plans. I was told to bill for a provider using a different credentialing than what the provider had. It wasn't up coding, but it still felt wrong and very unethical. The only reason the clinic wanted me to bill this way was because the rendering provider wasn't credentialing with Medicaid just yet, and since all claims went under the BCBA, they didn't see it as a problem. I tried to explain to the office and my boss that it didn't feel ethical but was met with rude messages from the clinic and my boss didn't seem to see anything wrong with it. The provider they wanted me to down code for had never even had the credentialing that they wanted me to submit the claims for. The provider was an actually BCBA, so claims should have been submitted under her NPI...I left shortly after. If it is one thing I understand...don't mess with government payers.

[alonawhalen]

In 2000 I had friends being diagnosed with COPD. Friends that never smoked a day in their life. Different Doctors, different clinics. Cigarette smoking way down, why did they get this diagnosis? There was a lawsuit that found Cigarette companies liable for Smoking caused illnesses. Bronchitis does not qualify for that cash. COPD does

[wednesdayschild]

I heard of a doctor that put a fake xray picture on a chart. He told the person they had a problem, charged 2000 for a new test. That scared the person for weeks.

[CiaRose]

I am a medicare advantage patient that the Kaiser optometrist. I asked if he could recommend a contact different than the company that I have been using for years. I found out that in order to get that question answered. I needed to get a contact fitting. I was skeptical since my optometrist that I have been going to for over 40 years. Always picked the contacts for my specific eyes. (Severe myopia, dry eyes and astigmatism)
Q: Can a non-physician charge a fee of 119.00 for a contact fitting? Her badge stated optical sales. Not optical assistant.

[jesusisdead]

I have a bill that I got after 3 years and they can't give me an itemized bill and the insurance company just paid 1500 3 years ago.. they gave me an out of network as I was dying. Surprise billing is illegal now but because it was legal back then they can charge me according to my insurance company. The insurance company says because the service date was in May of 2020 it doesn't matter the date of the bill. I thought the law was based on billing and not a service date

[balvinderBhatoya-gjns]

They steal my settlement upto headquerter

[truthbringer]

Let me break this down for those who don’t know they “why”

Insurance companies deny claims all the time in bad faith and nobody knows this better than the patient or their doctors, and insurance companies know hospitals and doctors up code bill, false code bill, double code bill, to their hearts content and they know the insurance company isn’t gonna say a word…. Because they (the doctors) know about the illegally denied claims, they know each others secret…. THIS IS WHY. Insurance companies go along with exorbitant bill coding because they consider it the cost of doing business in getting away with bad faith claims handling.

Always ask a lawyer