False Claims Act Impact On Medical Billing and Coding

Posted on December 26th, 2023 / Under Medical Billing / With No Comments

Initially, the False Claims Act in healthcare was enacted during the Civil wall to impose liability on individuals and organizations defrauding the government. This is why FCA is also known as Lincoln Law.

Since then, the False Claims Act has covered healthcare fraud and massively impacted medical billing and coding processes. Fraudulent billing practices lead to compliance issues, legal penalties, and improper reimbursement, so FCA is a critical deterrent for such practices.

Keep reading to learn about the False Claims Act in healthcare and the spectrum of fraudulent healthcare activities it addresses.

Understanding the False Claims Act

Medical billing and coding processes are highly complex, which is one reason these processes are vulnerable to intentional fraud and errors. For instance, submitting a claim for medical services that are deemed unnecessary or non-existent is a common intentional fraudulent activity that is covered under the False Claims Act.

A healthcare provider’s billing practices are governed under the False Claims Act once they contract with the state or federal government to treat Medicare beneficiaries. Under this contract, all medical claims are submitted to Medicare. In case of healthcare fraud, like unnecessary services, neglect, use of faulty equipment, and inadequate services, healthcare providers are liable for civil and criminal penalties. To avoid such penalties, providers must ensure billing and claim submission is accurate and compliant with healthcare regulations.

If reckless disregard or intentional misconduct of a provider is established, Medicare can directly sue them in civil court. It is crucial to note that the court can impose liability without finding the provider’s specific intent to defraud.

The mere submission of a false claim to Medicare is considered a clear violation, irrelevant to the payment status of the claim. In 2021, healthcare fraud accounted for over $5 billion of the total $5.6 billion Department of Justice’s False Claims Act’s settlements and judgments.

Some Federal False Claims Act examples are: 

  1. Intentionally present a false claim or cause it to be present to obtain payment from the federal government. 
  2. Defraud the government by getting a false claim approved or paid. 
  3. Create, use, or influence the creation of a false statement or record for reimbursement. 
  4. Create, cause to be created, or intentionally use a false document, record, or statement to decrease, completely avoid, or conceal the obligation to pay or transmit property to the government.

Difference Between Billing Fraud and Abuse


In billing, fraud is defined as the act of willfully planning or executing a scheme to defraud the federal government and obtain income from healthcare programs such as Medicare. Fraud is attempted through fraudulent representations or any payment or property that is under the custody of the healthcare benefit program.

Examples of billing fraud include:

  1. Billing for more services than the patient received.
  2. Billing for premium medical equipment while substituting standard or faulty equipment during treatment.
  3. Misrepresentation of the date of service to justify higher reimbursement.
  4. Inconsistent medical documentation submitted with a billed service.
  5. Gaining duplicate payments through double billing.


Billing abuse is not always intentional, but if it becomes consistent, it can be termed as healthcare fraud. It is defined as a provider or contractor’s behavior or conduct that is inconsistent and contradicts the standards of any business, medical practice, or insurance company.

Examples of billing abuse include:

  1. Waiving co-pays or co-insurance to encourage the patient to obtain further treatment.
  2. Billing from an out-of-network location while requesting pre-authorization under the network’s location.
  3. Conducting experimental services that do not meet a specific standard.
  4. Exaggerating or misrepresenting a diagnosis.
  5. Not disclosing discounts or hidden payments beforehand.

How False Claim Act Is Brought

The False Claim Act comes into play under two circumstances. One is when a former or current employee of a medical practice, with adequate knowledge of internal fraudulent activities being performed in the practice, files a lawsuit on behalf of the government.

They can also be called a whistleblower or relator in this scenario. Whistleblowers can be awarded around 10 to 30 percent of the total amount recovered in the lawsuit for filing the qui tam claim.

On the other hand, the U.S. Department of Justice can also file a False Claim Act if they have information on false claims being submitted by a practice. The DOJ also files claims for fraudulent healthcare practices when they learn about them through another local, state, or federal agency.

Penalties for Violating the False Claims Act

If a provider or healthcare facility violates the False Claims Act, the penalties can include:

  1. Repayments: Under the court’s order, the provider or medical practice can be ordered to make repayments to the healthcare benefit program such as Medicare, Medicaid, or Tricare. 
  2. Corporate Integrity Agreements: When a provider, organization, or entity enters a corporate integrity agreement, they must meet specific criteria before being able to bill a federal agency for the services they provide. 
  3. Treble Damages: Healthcare providers that make illegal self-referrals or kickbacks, billing Medicare a total of $1 million, can be sued and court-ordered to pay $3 million in damages. 
  4. Statutory Penalties: A single False Claims Act violation is worth $11,000 in damages. So, if a provider violates the Act once, they can be legally required to pay $11,000 in damages.


What is an example of False Claims Act Healthcare?

A common False Claims Act violation committed in the healthcare industry is upcoding, where the hospital assigns codes of expensive services to standard or inexpensive services provided to the patient. This is done to increase reimbursement obtained from Medicare.

How does the False Claims Act affect medical billing?

False Claims Act impacts a healthcare organization’s billing practices by deterring fraudulent activities. Providers that engage in improper billing will be subject to legal repercussions, including hefty fines and exclusions from healthcare benefit programs.

Why does the False Claims Act matter to healthcare providers?

The False Claims Act enables the federal government to bring lawsuits against healthcare providers engaging in billing abuse or fraud, promoting ethical billing practices in the healthcare industry.


Role of Encounter Forms in Provider Records and Billing

Posted on December 22nd, 2023 / Under Medical Billing / With No Comments

On average, a doctor works around 51.4 hours a week, seeing around 11-20 patients a day. With these numbers, it’s challenging for hospitals to efficiently keep track of patient information without proper staff or encounter forms.

Comprehensive and organized medical records are the cornerstone of effective management of a healthcare facility and delivering high-quality care.

Encounter forms have become more crucial for billing ever since the digitization of medical records. Encounter forms systematically encapsulate information about billable treatments, making the medical billing process more seamless.

Keep reading to explore further the role of encounter forms in patient-provider relationships and billing.

What Is a Superbill or Encounter Form?

Encounter forms or superbills are documents containing comprehensive summaries of patient encounters, diagnoses and procedural codes, and treatments performed. In short, these forms withhold the insights of each interaction between a healthcare provider and a patient.

This standardized information streamlines the billing and reimbursement cycle through timely and accurate claim submission. Encounter forms also contain insurance and patient demographics.

Here are some things included in superbills.

  1. Basic patient information, including patient identification number. 
  2. Demographic information like occupation and ethnicity. 
  3. List of physicians assigned to the patient’s case. 
  4. The reason behind the patient’s visit. 
  5. Past medical history of the patient. 
  6. Detailed information about the patient’s current illness, the onset, duration, and progression of the illness.  
  7. The complexity of visits and assigned procedural and diagnosis codes. 
  8. Staff and provider signatures indicating approval of the encounter form or superbill.

Examples of Encounter Forms

The layout and formats of encounter forms differ depending on the specific needs of the facility and the nature of the medical case. For example, dental care encounter forms include information like x-ray results, oral examination findings, dental history, treatment plans, and follow-up care.

Other examples of encounter forms include specialty-specific encounter forms, such as cardiology or neurology forms, gyne encounter forms, psychiatric encounter forms, pediatric superbills, and primary care encounter forms.

These examples will help you thoroughly understand what is an encounter form. It is crucial to record accurate information on superbills for effective treatment planning and preventing billing errors.

Importance of Encounter Forms In Billing

The information present in an encounter form is critical for multiple purposes. For instance, superbills enhance communication and collaboration among the healthcare staff as well as between the patient and provider.

With essential information regarding the patient’s condition being readily available, any changes in the treatment plans and further specialist recommendations can be conveyed easily.

Comprehensive documentation, such as patient encounter forms, allows healthcare organizations to maintain consistent and thorough patient records.

Information relevant to reimbursement and billing is also included in medical encounter forms. The standardized format used in patient encounter forms makes it easier to record medical diagnoses and services and translate them into codes. This contributes to coding compliance.

Due to encounter forms, claims can be submitted on time, preventing delayed or denied reimbursements. These documented records also assist healthcare facilities in legal inquiries and audits and ensure the facility is compliant with healthcare regulations.

All facilities use electronic encounter forms for their patients because manually filling in the form and adding signatures to approve each form increases the administrative burden on the hospital’s staff.

With digitized encounter forms or superbills, providers have more time to focus on providing high-quality care to their patients. Another way encounter forms improve the quality of patient care is by allowing providers to identify and eliminate any negative patterns and outcomes documented in previous forms.

Hospitals can encounter liability issues now and then, and without detailed records of patient encounters, it can be difficult to mitigate the risk of legal penalties. With complete information on recommendations made and treatments administered to the patient, providers and healthcare facilities can avoid potential liability claims.


What are the key components of Superbills/ Encounter Forms in medical billing?

The content recorded in superbills or encounter forms can differ by each patient encounter, but some key components of these forms include ICD-10 and CPT codes, modifiers, tracking units of services, patient demographics, medical history, breakdown of services provided to patients, and provider details. 

Information needed on a comprehensive Superbills includes?

If you’re wondering in what format a superbill comes, you should know that comprehensive superbills include insurance coverage information, patient instructions, fee schedules, and quantity and units or rendered procedures, along with basic patient information, medical history, translation of services into billable codes, and provider information. 

4 Examples of Superbills in Healthcare?

Superbills are defined as detailed invoices outlining services rendered to patients. There are different types of superbills detailing specific information. Some examples of superbills include dermatology and dermatology practices. These superbills include dermatologic procedures, dates of service, patient data, and any corresponding codes. Other examples include primary care superbill, orthopedic superbill, and gynecology superbill. 


Free Standing Emergency Rooms Billing Services And Your Need To Outsource

Posted on December 21st, 2023 / Under Medical Billing / With No Comments

Freestanding ER may be a new trend in the healthcare industry, but they have been around for ages. The purpose of freestanding emergency departments is to provide emergency care beyond the four walls of a healthcare facility. 

Emergency room billing is a major contribution to a hospital’s total workload, and managing patient care and physician billing duties can be hectic and challenging. This is why most organizations outsource this aspect, saving them time and money. 

However, outsourcing emergency room billing is not as straightforward as it seems. Let’s take a look at the challenges and benefits of outsourcing free standing er billing.

Understanding Freestanding ER

Freestanding emergency rooms are standalone ERs that are not connected or in the locality of a hospital. However, they are owned by a hospital or an organization. 

Having been around for nearly 50 years now, these freestanding emergency departments are easily accessible in communities. 

To ensure the highest quality of patient care, freestanding emergency departments are equipped with advanced and innovative medical technologies. FSERs are also staffed by highly skilled providers, including trained paramedics, nurses, physicians, and other support staff. 

Since these departments are designed to handle a diverse array of medical cases effectively, patients who visit freestanding emergency rooms can expect a high level of patient care to be delivered.

However, patients must remember that these freestanding emergency rooms may have distinct billing practices. For instance, most Freestanding ERs may not be directly affiliated with most insurance networks.

Awareness of any insurance implications and services provided can help patients make informed decisions when seeking medical assistance in a freestanding emergency room.

Differences Between Hospital ERs and Freestanding ERs

To fully understand what is a freestanding emergency room, you should learn about some differences between hospital emergency rooms and freestanding ERs.

While both ERs are open around the clock, seven days a week, one notable difference is the geographic location.

Hospital ERs are generally located in urban areas, mainly in general hospitals, which can be inaccessible to certain communities. However, freestanding ERs are strategically placed in areas where they can be accessible to communities.

Another difference is that patients have access to a wide range of specialists when seeking medical assistance in a hospital ER, but that might not be the case in a freestanding ER, although patients receive comprehensive care in both facilities.

FSERs have short wait times compared to hospital ERs, and their billing practices can also vary. Hospital ER billing is generally integrated with the hospital billing system.

Common Issues With Outsourcing Freestanding ER Billing

Here are some common issues with outsourcing free standing ER billing:

Privacy Concerns: Sensitive patient information must be kept confidential according to HIPAA regulations. Healthcare providers must partner with outsourcing billing services with robust security measures. 

Hidden Fees: Some outsourcing billing partners may impose hidden fees once you enter a contract. Ensure that you research thoroughly and partner with a billing service that helps you minimize operational costs. 

Slow Response Time: Slow response time from your outsourcing billing partner can have severe financial implications. Timely billing is critical for maintaining cash flow.

Benefits of Outsourcing Freestanding Emergency Room Billing

While there are certain drawbacks of outsourcing freestanding emergency room billing, the advantages of doing so outweigh the issues.

Let’s dive into the benefits of outsourcing ER billing for healthcare organizations.

Reduced Administrative Burden

Outsourcing is a great way for healthcare providers to offload some billing responsibilities, including claim submission, payment posting, and following up on claim status.

All of the organization’s resources can be focused on more practical objectives by outsourcing freestanding emergency billing, including investing time and effort in more patient-focused activities.

Fewer Billing and Coding Errors

Billing and coding errors can be a major concern for any healthcare organization, causing the internal staff and providers to divide their attention between providing high-quality patient care and addressing billing issues. 

Outsourcing medical billing for your freestanding emergency department to qualified medical billers will ensure billing is performed in compliance with current industry laws and with the help of technological advancement. 

This would improve the overall accuracy of billing processes and reduce claim denials.

Improved Cash Flow

Improved cash flow is one of the biggest benefits of outsourcing freestanding ER billing. For one, it can help you avoid a significant backlog created by not developing and submitting medical claims on time.

When the claims are filed and developed on time, it will improve cash flow. Consistent cash flow results in improved income streams for the facility.

Patient Satisfaction

Delivering high-quality patient care is the primary goal of every healthcare facility. By outsourcing your freestanding ER billing practices, providers can give patients their undivided attention, improving patient satisfaction.

Mitigating Compliance Risks

Healthcare facilities need to stay updated on coding requirements to reduce coding errors. Errors in coding can not only be costly but also result in severe legal penalties.

However, if you outsource billing and coding of your freestanding ER department, coding and billing experts well-versed in coding and other healthcare regulations will perform accurate coding, helping you avoid legal repercussions and mitigating compliance risks.


What is a freestanding ER room?

Freestanding ER departments provide patients with emergency care similar to hospital ERs, but they are not located inside or attached to a hospital. Instead, they are located close to communities to make ER services accessible to patients. Freestanding ER departments are open throughout the day, unlike urgent care centers.

Are stand-alone ERs more expensive?

While the cost of care depends on the type of procedures and services rendered to a patient, freestanding or stand-alone ERs can be more expensive than hospital ERs.


Physician Credentialing Importance In Healthcare Improvement

Posted on December 19th, 2023 / Under Medical Billing / With No Comments

According to a recent survey, 26% of physicians state that patients can be potentially protected against malpractice and other medical errors with the help of physician credentialing. 

Medical or provider credentialing extends beyond the assessment of a provider’s academic achievements, it encompasses a comprehensive evaluation of their experience, clinical skills, and ethical standing.

Credentialing in medical billing is a challenging task, and to make it accountable and steer clear of potential mistakes, here is what you need to know. 

Overview of Physician Credentialing

To put it in simpler terms, credentialing in medical billing is a process through which healthcare facilities evaluate the eligibility of prospective practitioners. 

The process involves validating physicians’ certifications and licenses, confirming their work history and malpractice coverage, and assessing their education and training.

The legal authority of staff selection and overseeing the credentialing process lies with the official board of a hospital. 

Not just that, insurance providers and other healthcare facilities also utilize the medical credentialing process to verify healthcare providers including therapists, pharmacists, dentists, nurses, and physicians. 

Each time a healthcare provider switches specialties or opens a new practice, they must undergo credentialing. Physician credentialing services ensure that patients receive care from healthcare providers that meet certain standards of professionalism. 

How Does It Work?

So, exactly does provider credentialing work? It involves three stages: credentialing, privileging, and enrollment or contracting. 

Many people tend to confuse credentialing with privileging, which is an entirely different process. 

While medical billing credentialing is the evaluation of a doctor’s qualifications, privileging done at healthcare facilities and hospitals provides credentialed physicians with the authority to perform specific procedures. For example, a physician granted privilege by the hospital can perform procedures like endoscopy. 

Privileging is granted by conducting OPPE (Ongoing Professional Practice Evaluation) and FPPE, which is a more focused evaluation conducted only if there are concerns related to the physician’s practice. 

This step comes after credentialing in the provider credentialing process. The third step is contracting in physician medical billing. This entails the involvement of payers and insurance companies. 

In this step, physicians apply for participation in health insurance networks. After approval, the physician enters a legal agreement in which specific terms and reimbursement rates are settled, allowing physicians to bill for their services.

If you’re confused about how to get credentialed with insurance companies, here are some steps you can follow:

  1. Researching potential insurance providers. 
  2. Gathering mandatory documentation. 
  3. Filing a Council of Affordable Quality Healthcare application for a provider identifier. 
  4. Follow-ups and re-credentialing.


Appropriate credentials are crucial for providers to perform treatment and get reimbursement. And if a provider has been credentialed, the process does not stop there.

The medical industry is continuously evolving, and to meet certain criteria, providers undergo re-enrollment or re-credentialing every two years or so. 

Once the credentials expire, providers receive a letter entailing a re-credentialing deadline. Repetition of the same credentialing process by a medical credentialing specialist ensures that the provider’s skills are up to par.

Importance and Significant Benefits of Credentialing In Healthcare

After knowing what credentialing is in healthcare, you may still be wondering why it’s important. 

Let’s dive right into how credentialing is directly linked to healthcare improvement. 

  • Avoiding Lawsuits: It’s not uncommon for healthcare organizations to confront false claims and lawsuits. When that happens, credentialing can help protect the organization and its providers. 
  • Safeguarding Patient Wellbeing: Patient safety is one of the primary objectives of provider credentialing. Any issues in the provider’s work history are uncovered during the credentialing process.
  • Building a Reputation In the Industry: Medical credentialing also plays a critical role in preserving and shaping the reputation of a healthcare facility as it validates the qualifications of healthcare providers. 
  • Prevents Loss of Revenue: Proper physician credentialing reduces delayed reimbursements, preventing thousands of dollars worth of loss in revenue of a medical practice. 
  • Access to Patient Bases: Credentialing allows practices to boost their revenue streams by accessing more patient bases, such as patients covered under health insurance. 
  • Delivering a Competitive Edge: Qualified practitioners are more inclined to join credentialed facilities and similarly, you can enlist professional and highly skilled providers in your practice through medical billing credentialing. 

Common Physician Credentialing Mistakes 

Allocating adequate resources to properly credential each provider can be a hassle most organizations are not equipped for. Extremely lengthy credentialing processes are one of the basic causes of provider credentialing mistakes. 

With that said, here are some common credentialing mistakes on the provider’s end. 

  1. Providing inaccurate or outdated information during credentialing. 
  2. No follow-ups on re-credentialing and failure to respond to requests for additional documentation. 
  3. Submitting expired credentials. 
  4. Not disclosing issues about former work history, such as malpractice. 
  5. Failure to track expiration dates of licenses and certificates. 

On the other hand, there are also common credentialing mistakes on the staff’s end that can lead to errors. 

  1. Inaccurate data entry can lead to confusion. 
  2. Delaying provider credentials and not acquiring provider credentialing services. 
  3. Allowing providers to practice and perform treatments before credentialing is complete. 
  4. Relying on manual workflow instead of automating the credentialing process. 
  5. Not using primary source verification to avoid errors. 


What are the provider credentialing process steps?

The provider credentialing steps include researching documentation requirements, selecting insurance providers, ensuring the accuracy of the information, completing the CAQH, waiting for the insurer’s approval, follow-up, and re-certification. 

What makes credentialing in medical billing essential?

Credentialing in medical billing is essential for numerous reasons, including reduction in medical errors, streamlining the reimbursement process, compliance, maintaining professionalism, and maintaining patients’ confidence in the providers treating them.


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