Hospitals and medical practices that accept Medicare have to adhere to strict standards. There are licensing requirements and basic care standards that the facility must meet. There are also many financial rules that the medical business must accept to accept Medicare coverage. Medicare imposes limits on billing. The program negotiates bundled discounts for services often provided together and sets maximum compensation rates for different types of care.
Health care professionals and the office workers overseeing medical billing can sometimes engage in conduct that looks like fraud. Attempts to work around Medicare rules may ultimately lead to legal controversy. The business could be subject to an audit or other major consequences if there are indicators of fraudulent billing activity.
In recent years, phantom billing has emerged as one of the most costly forms of Medicare billing fraud. Those accused of phantom billing could be subject to a thorough record review and could be at risk of financial consequences, including ineligibility to cooperate with the Medicare program in the future.
What is phantom billing?
Phantom billing involves submitting an insurance claim for services not rendered. A pharmacy might bill Medicare for a prescription submitted by a doctor that a patient never collected. A family practice medical office might bill for an appointment that a patient canceled with minimal notice. Particularly if the facility charges a sizable cancellation fee to deter no-shows, billing Medicare for the appointment may seem more compassionate than charging the patient the fee.
Unfortunately, that decision could lead to major consequences. Sometimes, allegations of phantom billing relate to communication or record-keeping errors. Other times, phantom billing is a common practice at a medical facility that could generate thousands of dollars in revenue.
What are the consequences of phantom billing?
A records audit is arguably the least severe outcome of allegations of Medicare billing fraud. Professionals could be at risk of disciplinary action that could affect their licensing. Criminal charges could follow substantiated allegations of billing fraud. Professionals might face criminal penalties and orders of restitution that cost them tens of thousands of dollars.
Medical facilities embroiled in a Medicare billing controversy and facing Medicare audits may need help preparing for the process ahead, and that’s okay. Understanding what types of billing practices could lead to fraud allegations and audits can help limit organizational exposure due to inappropriate billing practices.
