Many patients and insurance companies end up paying or covering outrageous bills due to errors or incorrect medical billing. Erroneous medical billing drives up costs and drains resources from insurance companies, irrespective of the cause of the human error or deliberate abuse of the system.

“Incorrect medical billing affects everyone, from the providers who may face claim denial to insurance companies incurring extra cost and the patients who pay higher premiums,” says Russ Berkowitz of Berkowitz Hanna Malpractice & Injury Lawyers. It is therefore vital to hire a medical billing expert. Also, there is a need for patients and insurance providers to watch out for unlawful upcoding of services.

What Does Upcoding Mean in Medical Billing?

Upcoding is a type of fraudulent medical billing. In upcoding, the cost of a health service that health providers bill is higher than it should have been based on the service rendered. Any payer, including the patient, Medicaid, Medicare, and private health insurers, can receive an upcoded bill.

Even though it is not the standard, Upcoding can happen when you receive diagnostic services, undergo medical procedures, or see your healthcare provider. The cost of healthcare will go up for everyone due to upcoding. The reason is that everyone pays for healthcare through the government and private payers who distribute the cost among everyone.

Who Verifies Correct Medical Billing?

The medical billing experts ensure the correct billing of the medical care. Ensuring patients receive accurate medical billing will help stop financial abuse of patients, which often occurs when they are most vulnerable.

To accomplish this, the medical billing expert must verify the services rendered by the health provider by comparing the medical record to the billed charges. Additionally, the expert identifies the Usual, Customary, and Reasonable (UCR) fees according to the American Medical Association (AMA) definitions with the application at the 75th–80th percentile.

How the Usual, Customary, and Reasonable (UCR) Charges Work

UCR is the sum paid for a medical service based on what providers usually charge for similar medical services in a given geographic area. Some health plans base the allowable coverage fee on the UCR amount (what an insurance company will approve). Unlike managed care plans, indemnity health insurance allows you to pick your providers, and the insurer covers a certain percentage of your medical expenses.

Usually, insurers use the UCR to determine how much they will pay. The result could be that you may pay more and sometimes much more than your usual cost percentage. For instance, if your doctor charges $100 ( your UCR insurer amount), your insurer is expected to cover 80 percent of the bill, they would pay $80 as expected, and you would pay $20. Even if the doctor charges $150, the insurer will only cover 80 percent of the $100 UCR ($80).

Therefore, find out if your insurance depends on UCR charges before having any treatment. Compare your provider charges to what your insurance company considers Usual, Customary, and Reasonable.

Other Reasons Why you Need a Medical Billing Expert

Lawyers, health practitioners, and patients can benefit from the assistance of medical billing experts. They can help these groups in the following ways:

1. Proving Damages

Plaintiffs in personal injury cases have a right to compensation for their medical costs from the negligent parties. However, the plaintiff will need to prove that claim with expert testimony if the defendants refuse to acknowledge or agree to the reasonableness of medical bills. In a situation like this is where a medical billing expert can help.

Medical billing experts use credible methodologies to assess whether medical billings are reasonable. Medical billing experts compare billings to the prices other doctors in the same community charge for the same services using databases and information they gather. Medical billing experts also assist attorneys in overcoming the Daubert challenges by writing thorough reports showing reliable data-backed conclusions.

They also describe how other medical billing experts across the nation have accepted their approach to overcoming the Daubert challenges. The Daubert challenge is one of the legal defense strategies opposing counsel can use. The Daubert challenge could result in the complete exclusion of the testimony by the medical billing expert and cast doubt on its reliability.

2. Addressing Insurance Claim Denials

Medical practitioners usually hire medical billing experts when insurance companies unfairly refuse to pay their medical billings. In some cases, insurers are lawfully supposed to cover the Usual, Customary, and Reasonable (UCR) cost of the services received by the insured. Insurance companies sometimes use their payment rates without attempting to calculate the UCR rate.

Medical billing experts can support doctors in proving that their billings fall within the reasonable range of UCR rates within the area of service provision. They can achieve this through the use of databases and other information sources.

Furthermore, Insurance companies deny claims when they think a doctor used the wrong Current Procedural Terminology (CPT) code. A medical billing expert can identify whether there was indeed a mistake and assist the doctor in fixing it for the billing acceptance. If the billing does not show a wrong CPT code, a billing expert can write a report outlining why the correct code appears on the billing.

3. Fraud Detection

It is common knowledge that some medical practitioners purposely overcharge their patients, insurance firms, or Medicare. The following are some ways they can accomplish this:

  • Billing for services they did not render to the patient
  • Billing for similar service twice
  • Placing a separate price on services that ought to have been bundled and billed as a single service
  • Not describing the service they rendered with the proper CPT code

Sometimes, patients may choose to file fraud lawsuits against their healthcare providers. Lawyers may even file a class-action lawsuit against a healthcare provider who routinely overbills numerous patients in the same manner. Medical billing experts can help provide essential supporting evidence in favor of those lawsuits.

Final Thought

Everyone pays for inaccurate medical bills, from the providers who risk having their claim denied to the insurance companies covering additional expenses. Patients also face premium and healthcare overcharging. Thus, health providers should hire a medical billing expert to ensure accurate billings to avoid all these inconveniences.