Outsourcing Medical Billing to Prevent Fraud

outsourcing medical billing, Outsourcing Medical Billing to Prevent Fraud

Even noble fields like healthcare are fraught with billing fraud, as sad as it sounds. In one of our previous entries, you learned what to consider if you’re thinking about outsourcing medical billing. Just recently, Becker’s hospital review rounded up a list of recent medical fraud cases that cost millions. Here are the five most common forms of medical fraud that can happen undetected, if medical billing function is not sufficiently supported: 


Upcoding happens when the healthcare provider deliberately submits a claim using an incorrect billing code to raise the reimbursable amount. Physicians’ complicity in upcoding exaggerates the severity of the condition to increase the billable amount. In some cases, fraudsters claim that patients consult with doctors that charge higher but in reality, only consult with nurses. 


Fraudsters resort to unbundling a code of one big medical package to get paid for separate services. Unbundling commonly happens in laboratory tests. Some doctors order a series of tests together frequently so these are bundled under one code. Outsourced medical billing professionals encounter laboratories that “unbundle” these into individual tests so that they get bigger reimbursements. 

outsourcing medical billing, Outsourcing Medical Billing to Prevent Fraud

Double Billing 

The term is pretty self-explanatory. This pertains to charging or claiming for reimbursement more than once for a service. Fraudsters have a number of tricks up their sleeve to conceal double billing. They will bill different providers on separate dates to evade detection. 

Misrepresentation of patient

Also known as medical theft identity, perpetrators use the personal information of a past or deceased patient to submit fraudulent claims for reimbursement. Medical theft isn’t just harmful to health care insurance providers. This can also hurt the credit record of unknowing patients whose identities are stolen for misrepresented claims. 

Billing for non-covered services

Healthcare providers have a complicated web of covered and non-covered services. Fraudsters take advantage of this by simply labeling non-covered services as “covered.” Many of them get away with this due to the sheer amount of claims processed in a day, especially if these services have similarities with the covered services. 

Will outsourcing medical billing catch fraudsters red-handed?

The pressure for healthcare providers to perform has increased in the past years, with health and wellness services having taken center stage in all aspects of life. These providers must scale up the efficiency of their operations to deliver. Having a fresh pair of eyes monitor claims will ensure that every claim is thoroughly checked and deserving of a reimbursement. 

Outsourcing services really specialize in a certain service, medical billing, in this case, so you’re ensured that the team assigned to you is well-equipped to handle medical billing and collections to insurance pre-authorization and claims processing. 

The medical billing team of MCVO Talent Outsourcing Services has sharpened their skills in spotting medical fraud, from years of experience in handling medical billing for clients across the globe. If you are thinking of outsourcing medical billing to a veteran group and focusing on the actual healthcare services, set an appointment to meet the billing team for you.

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