Validated — Double-Billing on Healthcare Claims Is Real
Background
ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication do not catch, leading to greater savings for medical plans and plan members. ClaimDOC’s audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, double billing of services, incorrect coding, incorrect units, unbundling of services, and many others. Claims review is not intended to impact care decisions or medical practice.
In this Audit Spotlight, we focus on due diligence — closely reviewing claims and keeping in mind double-billing on healthcare claims is real.
Double-billing occurs when a provider attempts to bill Medicare/Medicaid and either a private insurance company or the patient for the same service/treatment, or when two providers attempt to get reimbursed for services rendered to the same patient for the same procedure on the same date of service. If double-billing is intentional, then it is a form of fraud. The Office of Inspector General has expressed concerns about double-billing and other abusive billing practices for several years. While detailed percentages of double-billing are not always publicized, the OIG, Medicare, Medicaid, health plans and numerous other groups/organizations have consistently highlighted the associated risks of double-billing.
As healthcare costs continue to climb an upward slope, an escalated need exists for closer analysis of healthcare claims to identify egregious charges, improper medical coding and billing errors, double billing, duplicate billing, and associated improper claim payments.
Case Example of Double-Billing
A 25-year-old male was seen and treated for the diagnosis of gastroenteritis in a licensed freestanding emergency room in Texas. The freestanding ER reported/billed services on the UB-04 claim/electronic equivalent for the care provided.
Total billed charges for freestanding ER services — $18,731.
The physician seeing/treating the patient in the freestanding ER reported/billed services on a CMS-1500 claim/electronic equivalent.
Total billed charges for physician services — $12,481.
Total combined freestanding ER (facility) charges and physician charges — $31,212.
ClaimDOC Auditor Analysis and Findings
During the ClaimDOC auditor’s review and comparison of the physician claim alongside the freestanding ER claim, it was identified the physician billed three of the same services billed by the freestanding ER. While this might be feasible in some instances, it raised a red flag, requiring due diligence to determine if double-billing occurred.
The freestanding ER is appropriate to report/bill the services performed in the facility setting for the costs it incurs, i.e., overhead, building, staff, medical records, equipment, other.
The physician is appropriate to report/bill the services/care he/she performs in the freestanding ER.
Physician Claim
The physician reported and billed the following three (3) services:
- Emergency room visit (CPT code 99284) and related charge of $5,462.
- Covid laboratory test (CPT code 0202U) and related charge of $6,809.
- Procedure of flush/irrigation of venous access device (CPT code 96523) and related charge of $210.
Total Physician Charges — $12,481.
ClaimDOC pricing for the physician professional service (CPT code 99284 — ER Visit) — $149.31.
The two CPT codes (0202U and 96523) billed by the physician were deemed as duplicate/double-billed services as these codes were also reported/billed by the freestanding ER. In this instance, only the facility may report the services and related charges.
Incorrect physician billed charges of $7,019.
Freestanding ER Claim
Charges for the same three (3) services:
- Emergency room visit (CPT code 99284) and related charge of $6,374.
- Covid laboratory test (CPT code 0202U) and related charge of $7,945.
- Procedure (CPT code 96523) and related charge of $210.
- Other services reported/billed on the freestanding ER claim (venipuncture, medical/surgical supplies) related charges of $4,202.
Total billed charges for freestanding ER services — $18,731.
ClaimDOC pricing for freestanding ER services — $1,362.41.
The Takeaway
Double-billing cheats the system and causes losses including wrong copayment amounts collected from patients, inaccurate claims data, premium increases to cover losses from fraud and raises costs for patients and employers. Ethical responsibility requires healthcare providers to have ongoing and effective coding/billing compliance programs as well as maintaining price transparency and fairness in billing practices.
Given the volume of healthcare claims that are reported/billed each day by providers/suppliers, medical bill errors and egregious charges are alarmingly common and lead to abuse, waste and fraud.
When an individual receives a healthcare bill that appears questionable/inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charges.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Our high-quality and expert review of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities. Employers turn to us seeking to establish fair reimbursement rates for their plans, allowing them to save money and provide richer benefits to their employees — a win-win for everyone.