| For obvious reasons, medical billing is essential in | | | | are most likely to be targeted for audits or |
| the practice of medicine. Just like everyone else, | | | | investigations: billing for items or services not |
| doctors want to be paid for their services. While | | | | provided, submitting claims for services or |
| timely and proper billing is the key to financial | | | | equipment which is not medically necessary, |
| success and stability of a medical practice, | | | | double billing, billing for services not covered by |
| improper billing practices may get a physician in | | | | the program and representing that a covered |
| trouble beyond any imagination. Medical billing and | | | | service was provided, failing to properly use |
| keeping medical records are two absolutely | | | | coding modifiers, clustering, and upcoding the level |
| interrelated areas and proper documentation | | | | of service provided. |
| maintenance is crucial to avoiding many billing | | | | The proper keeping of documentation in the |
| issues. | | | | medical records is the proven way to avoid many |
| Physicians are not trained to be medical billers; | | | | potential problems and minimize damages in case |
| most practices employ billing professionals or | | | | potential problems become real. Properly |
| medical management companies to handle all billing | | | | maintained medical record documentation may be |
| issues. However, it is ultimately the doctor's | | | | used by defense in an investigation or an audit to |
| responsibility to make sure that the claims are | | | | determine what services were provided and who |
| valid and all the regulatory requirements are met | | | | provided them. Most importantly, it could be |
| when the claims are submitted to payers. | | | | established that there existed a reasonable |
| There are many potential payers but Medicare | | | | medical necessity for the services. Many billing |
| and Medicaid are clearly the largest ones, followed | | | | issues may be resolved early in the investigative |
| by insurance companies and HMOs. Each payer | | | | process when a physician is able to demonstrate |
| has a complicated system of payment policies | | | | that his or her billing was accurate and appropriate. |
| and procedures, many of which are constantly | | | | A good medical record will contain information |
| changing. Failure to comply with the established | | | | about reason patient sought the practitioner's help, |
| billing procedures is likely to result in an audit or | | | | relevant medical history and diagnostic test |
| even a criminal investigation. Many federal | | | | results, physical exam findings, medical |
| Medicare fraud criminal prosecutions were | | | | assessment, clinical impression and diagnosis, the |
| triggered by medical billing audits and investigations. | | | | treatment plan, and date and signature of the |
| According to the Office of Inspector General's | | | | provider. |
| Compliance Guidance, the following billing activities | | | | |