How to Report Unethical Medical Billing Practices (2024)

Healthcare providers have to trust their coders and billers to maintain the highest standards, which include federal laws and industry regulations. Most take their responsibility seriously, but what can you do when you suspect fraud?

PracticeForces, amedical billing company in Florida, explains how to report unethical medical billing practices below.

What Are Unethical Billing Practices?

Unethical billing practices include any act that betrays or misleads a payer and results in overpayments, which constitutes fraud.

Your typical unethical billing covers a variety of practices, such as:

• Double billing: Billing the patient or their health insurance for the same procedure twice
• Upcoding: Billing the patient more by using a higher-valued code
• Phantom charges: Including charges in your medical bill for services the patient did not receive
• Unbundling: Charging a patient for individual services using separate codes where you could use a single code that covers the full care plan for that diagnosis
• Incorrect quantities: Charging the patient or insurer for more medical items or medications than the patient actually received
• Medical equipment fraud: Billing for equipment the patient did not receive
• Misrepresenting service dates and locations
• Waiving copayments or deductibles

Even though some of these practices may be done in error, they remain unethical. Why? Any of these practices can result in the provider receiving higher payments from a patient’s insurance company, the patient themselves, or another payer like Medicare.

What To Do If You Discover Errors on the Medical Bills You’re Sending Out

Although the vast majority of medical billing specialists are deeply ethical, mistakes happen. People may also willingly engage in practices that break the law because they have some external motivation to do so. In either case, knowing how to report unethical medical billing practices could reduce fraudulent claims while also saving money.

TheNo Surprises billing actof 2022 allows patients to dispute denied claims or bills of $400 or more than the “good faith estimate” that the provider gives to uninsured patients. Still, anyone who receives bills and suspects errors should first contact the billing department of their provider to request an explanation. Errors or inconsistencies usually have quick resolutions.

If this approach is ineffective, or you suspect unethical billing practices within your organization, the next step is escalation to one of these agencies:

• Health insurance company fraud departments
• The office of the state Attorney General
• State or federal Department of Health & Human Services
• State Medical Licensing Board
• The Centers for Medicaid and Medicare Services
• The FBI

What to Include in Your Unethical Billing Complaint

The process of reporting unethical medical billing depends on who you’re asking to investigate. At the very least, expect your contact to request the following evidence:

• Copies of unethical bills
• Communication records
• Documentation proving actions you’ve taken to rectify the issue

Do What’s Right With Help From PracticeForces’ Medical Coding and Billing Experts

Knowing how to report unethical medical billing practices could save you a headache (and money). If you just want to focus on providing exceptional care to your patients, why not work with PracticeForces to ensure your practice has zeroinaccurate coding and billing? Call (727) 499-0355 to learn more.