The Road to a Fraud-Free Clinic and Medical Circle!!

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When was the last time you have heard of fraud being perpetrated within medical circles?  Probably the Medicaid scam masterminded by an Armenian crime syndicate in the United States?  But the truth is many cases of medical fraud in the United States do not require the aid of organized crime group.  A case in point is the less dramatic but very important Gambro Dialysis Fraud of April 2006.  In what ultimately turned out to be the country’s sixth largest medical fraud case, Gambro Healthcare, whose parent company was based out of Stockholm, Sweden had to make payments in excess of $300 million for knowingly abetting fraudulent practices in billing and kickbacks, which resulted in precious funds being diverted from Medicare.  While it has been estimated that Medicare/Medicaid lost about $5 billion in 2006 due to improper billing practices, that figure substantially rose to $50 billion in 2010.

The thing about fraudulent practices is that many of its perpetrators may not be even aware that it is so.  The most common avenue for fraud in medical billing is via the “Phantom Billing” route, wherein the clinic bills for unnecessary procedures or those which were not performed, but still billed due to miscommunication within the clinic or lack of proper paperwork.   The latter of course could be taken care of by installing an EHR/EMR most relevant to your practice.  The former can be approached by conducting frequent internal medical coding audits to ensure that the medical coders are savvy and compliant with the latest medical coding guidelines or still easier, the medical coding operations may be outsourced to a dedicated medical coding vendor, who already has these stringent methods in place, thus saving you time and money.

But that being said, one still needs to be ever so ready for the RAC audits, which are all the more rampant in these days of pay-for-performance criteria.  Billing Paradise, a leader in technology enabled Medical Billing And Medical Coding Services, has also been serving as a third party consultant to clinics looking to learn more about RAC Audits in the shortest span of time.   That is because the audit consultants at Billing Paradise have both extensive experience as well as theoretical knowledge of what a clinic should expect when one of the four RAC contractors; Diversified Collection Services, CGI, Inc, Connolly, Inc, or HealthDataInsights gets in touch with them.

In addition to the above Billing Paradise can also help you with the following:

a. Conducting Internal Audits.

b. Learning the methodologies of compliance.

c. Rightsizing and outsourcing routine and repetitive medical transcription, medical billing, and medical coding functions.

d. Organizational Mapping.

Remember that data becomes information only if it can be utilized properly, and BillingParadise has always been aware of this universal axiom of the modern medical era.  Thus it has been our constant endeavour to help clinics collect, store, and manipulate data in ways that ultimately prove beneficial to them.

Call us at 1-888-571-9069 or  email us at  for all your medical data management needs, including but not limited to the above.

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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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