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Many medical practices don’t require a degree for you to work in their billing department. Some companies will even promote and train those who start as receptionists to move into billing if they stay with the practice for long enough.
Handling the accounts receivable and insurance billing for a medical practice requires attention to detail and excellent organizational skills. It also requires an understanding of insurance fraud in healthcare settings. Otherwise, you could unintentionally put yourself at risk of getting arrested and facing serious criminal charges.
Private insurance companies and federal insurance programs have rules for participating medical providers. Often, they negotiate specific reimbursement rates and discounts for procedures often performed together.
Some of the actions you take as a billing specialist for practices used by the company that employs you could violate insurance company rules or federal insurance law. For example, it is never legal to bill for procedures other than the one a doctor performed or for a procedure that didn’t take place. You shouldn’t alter the date or location of the treatment or try to manipulate the billing records to make an uncovered treatment seem like a covered one.
Upgrading the procedure to bill for extra money is a crime. It is also illegal to unbundle services. If the insurance provider, whether it’s a private company or Medicaid, set a specific rate for services performed together, it is illegal for you to bill individually for those services instead of at the agreed-upon, discounted rate.
You don’t need to profit from your company’s bad insurance practices to face criminal charges. Knowingly billing for false appointments, upgrading charges or otherwise manipulating the insurance billing system is enough to implicate you.
Even if you didn’t understand the possible consequences of your actions, participating in an illegal insurance scheme for the benefit of your employer could easily lead to white-collar criminal charges like health care insurance fraud allegations. If the policy involved is through a federal medical insurance program, the charges you face could be federal offenses other than state charges.
Recognizing the risks involved in medical billing work can help you properly respond to questionable requests by your employer or a criminal investigation.