Medicare Fraud- $11billion Gone on Unethical Coding Practices

 Erika Regulsky Tags: , , , , , , , , , , , , , , , , Practice Management, Software

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Of late there have been increasingly alarming statements emanating from the offices of CMS about seemingly blatant Medicare frauds.  “Nearly 50% of the claims submitted to Medicare in certain states are fraudulent and contain upcoding”.  “$11 billion has been lost by the Medicare coffers in the past decade due to unethical coding practices”.  Or the rather disturbing “A push towards electronic medical records is causing the higher-paying codes to be used”.   What really is the ground reality here?  Are things really this bad when it comes to medical billing and medical coding.  Is the push towards EMRs/EHRs really encouraging malpractice tendencies on the part of physicians/clinics?

Although various pro-physician bodies, including the AMA, have suggested a possible increasing complexity of the patient base as the reason for the steep usage of the larger-paying E&M codes, many present and past officials of CMS fail to buy the argument.   Analysis of the data collected by bodies such as Center for Public Integrity and Centers for Disease Control fail to find any average increase in patient age nor greater physician time being expended to explain the upcoding.  Thus CMS is pretty positive that many clinics, either knowingly or unknowingly, are exploiting the so-called loopholes that would be inherent in any behemoth of a system, processing more than 350 million claims a year.

Also, it has been pointed out by some CMS experts that medical billing via certain EMRs is actually encouraging the physicians/clinics to use the higher-reimbursing codes, since some EMR vendors do promise “an optimal choice of codes”, picked automatically by the system in order to increase bottom lines.  To counter all of the above, Medicare is placing increasing stress on RAC audits.  Even though the costs Vs benefits analysis of such audits increasingly point to a net gain of almost nothing monetarily, Medicare might actually intensify the frequencies of the audits to root out what it considers practices running counter to the principles of the Hippocratic oath.

To know more about where your clinic stands when it comes to RAC audits, and to decide on a federally compliant Medical Billing software, call us BillingParadise, on the toll-free at 1-(888)-571-9069 or email

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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