"A lot of people think that if they over code or up-code, it's the worst thing they can do. But, under-coding is just as bad," says P.J. Cloud-Moulds, a practice consultant and head of Turnaround Medical AR Recovery in Sioux Falls, S.D.
Under-coding happens when a practice fails to accurately code for all services they performed during a visit. This can leave valuable dollars on the table and cause incorrect reimbursement. The thing that makes under-coding so dangerous is that it's impossible to catch without an audit, and by that time "a small practice could have already shut down," says Cloud-Moulds.
Reasons for Mistakes
Why do practices continually make the same billing mistakes? It all starts with a lack of understanding, according to Cloud-Moulds. "Some physicians are consistently coding 'office visit, office visit, office visit.' But if you're doing something else during the visit, you need to code for it," she says.
Physicians go to medical school, not coding school, so a lack of knowledge can always be a factor, she adds.
Bewley points to the fact that health care laws are constantly changing and overly complex as to why billing mistakes are made over and over again. "Most physicians and practices that I work with are well intentioned. They aren't trying to do something fraudulent. But because there's so much scrutiny of billing and reimbursement, even unintentional errors can lead to a need to refund money to payers, and false claims act cases," says Bewley.
With health care regulations constantly changing, physicians not equipped with the latest information can find themselves in hot water. Physicians don't have a lot of free time to begin with, so setting time aside to keep up with coding and billing regulations can add to the burnout epidemic.
Outsourcing the billing and coding to a third party can take pressure off a practice, but it can also lead to unintentional error through communication breakdowns. Any time work is passed off, the chance of miscommunications become larger.
Elderly physicians may have a harder time adopting new regulations, as old habits are often hard to break, Fossum says. When a doctor has been in practice for many years, they sometimes stick to the billing codes they typically do in the office, he adds.
"A doctor who has been around 10 to 15 years still may have an encounter form or billing sheet and they just check off that they have done that procedure even though in the room they may have done various analogs to that procedure or other procedures," says Fossum.
Size Doesn't Matter
The government audits practices of all sizes, and thinking your practice is too small can lead to disaster, experts say.
Bewley spent part of his career with the Office of Inspector General for the Department of Health and Human Services, gaining insight on the ways the government views health care organizations. "As a former government [employee], I can say that the government doesn't have any criteria for audits or investigations, everyone is fair game."