Billing and Reimbursement Issues That Needs To Be Addressed

Medical services’ billing and reimbursement are among the most critical areas in any healthcare organization. Yet, a variety of common issues can occur with this process. These include fraud, duplicate billing, and high deductibles. This article will discuss these problems and provide some strategies for combating them.

High Deductibles

If you’re on the health insurance exchange, chances are you’ve encountered high deductibles and the accompanying billing and reimbursement issues. These common problems can be costly and can cause people to delay necessary medical care.

While high deductibles can help some people, they can also stifle access to care. According to a recent study, nearly 30 percent of adults with high deductibles avoided needed medical care.

The study also found that adults with full coverage were likelier to report medical bill issues than those with limited or no coverage. Even though these findings might not apply to high-deductible health plans, they point to the need for more excellent consumer education.

High deductibles can also create new revenue cycle challenges. For example, patients carrying higher debt loads are more likely to avoid care.

Consumers should be provided with timely information and price transparency. They should be made aware of the benefits of alternatives to deductibles, such as out-of-network care and preventive services.

There are also measures to encourage cost competition among healthcare providers. As the number of providers increases, consumers should be able to choose one that provides better value for their money. If consumers would encounter reimbursement issues, a few actions can be taken. The superbill payment could help you settle with your insurance company to compensate for your spending. 

Coding Errors

Coding and billing are the most critical steps in the revenue cycle. Incorrect billing and coding can result in claim denials, patient delays, and loss of revenue. This can lead to a financial disaster for smaller practices.

Medical coding is the stage in the revenue cycle when every procedure, test, or medicine is categorized by a universal code. CMS modifies these codes each quarter, making it essential for practices to be familiar with the latest rules and guidelines.

Many coding solutions are geared toward reviewing clinical documentation. It is also advisable to take an internal audit to determine the root causes of common errors. A simple finger slip can cost a practice thousands of dollars in lost revenue.

Getting your billing staff up to speed on the latest coding guidelines is a great way to avoid errors. Training and continuing education programs can ensure that your employees know the latest requirements.


Upcoding is an unethical medical practice in which a doctor or healthcare provider charges for services that are not provided. It may also involve the submission of incorrect billing codes to insurance companies.

Upcoding is a form of fraud that affects patients’ and taxpayers funded medical programs. Contact a lawyer to learn more about your rights if you are concerned about upcoding. A lawyer can help you navigate the complex process of a case and ensure you do not get into serious trouble.

Healthcare providers are required to submit valid billing codes to insurance companies. This enables the government to reimburse providers at specific rates. However, incorrect codes can result in inflated reimbursements. In addition, submitting the wrong code can lead to penalties.

Hospital inpatient care costs are calculated by predetermined rates and diagnosis codes. The prices vary by patient’s severity level and type of diagnosis. Some services are billed using Evaluation and Management (E/M) regulations, which reflect the complexity of the treatment. Doctors in complicated specialties may report the highest E/M service regardless of the type of patient’s condition.

Duplicate Billing

One of the more common healthcare problems is duplicate billing. It can be a minor error or something more serious. If you don’t pay attention to the details, you could pay for two services or one that isn’t delivered.

There are many reasons for this. For example, the billing department might need to correctly enter information into the system. Or the patient’s account might need to be updated. However, the cost of duplicate billing goes beyond the number of times it’s billed or paid.

Duplicate claims are not only a hassle but also a significant money drain. The best way to avoid these expenses is to review and verify each patient’s health record. That includes both demographics and medical history. Likewise, double-checking your billing software will ensure you’re not submitting a false claim.

Another reason a medical biller should be alert is the number of tests a patient might be subjected to. The billing system might enter the incorrect diagnostic code when multiple tests are ordered for a single patient. An error like this could indicate that the patient had x-rays of both legs.


Billing and reimbursement fraud is a common issue in the healthcare industry. If a provider has been involved in one of these schemes, they may be subject to a criminal charge or liable for civil monetary penalties under the False Claims Act.

While most healthcare providers can avoid billing and reimbursement fraud, others commit it without intending to do so. There are several different types of fraud, including cherry-picking and upcoding. In both cases, the provider deliberately omits critical information to cover errors in patient treatment.

Another common form of fraud is double billing. This occurs when a provider bills two public or commercial programs for the same service. The federal government and other payors should review their providers’ claims for troubling information.

Upcoding is medical billing fraud involving using a higher-than-necessary code for a particular service. The purpose is to fraudulently increase reimbursement. For instance, if a doctor charges for a procedure and does not perform it, the provider can upcode it to be a more expensive or labor-intensive service.

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