Upcoding, the fraudulent practice of submitting a billing code for a service that pays more than the service actually performed, is fraud. There's no doubt about that. It's wrong; it hurts patients, insurers, and society as a whole.
But, is everyone who has ever submitted an inaccurate billing code really an evil fraudster out to bilk the system of millions? Learn why not in "Why Upcoders Aren't Always Evil Fraudsters."
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What happens when a billion-dollar system is excessively complex and disconnects the shopper from the bill-paying? Upcoding fraud happens.
Upcoding takes advantage of two problems with the current health care reimbursement system.
- The consumer, the patient, has no idea how much the health care he's consuming costs.
- The complex nature of the billing-code system creates opportunity for fraud as well as for legitimate mistakes.
It's much harder to pull the wool over someone's eyes in a system that uses a "keep it simple, stupid" approach than it is in a system that requires an 89-page government document to explain how to correctly apply a series of a dozen or so frequently used office billing codes.
Be that as it may, the system we have is the system we must work within; it's everyone's responsibility to try to make it work correctly.
What does that mean to you, the patient or health care provider? It means you need to understand "The Lowdown on Upcoding--What It Is & How It Works." If you're the patient, it means you need to read each and every explanation of benefits and start asking questions if you don't understand the information on your EOB. If you're the health care provider, it means you need to make sure that a misunderstanding of the coding rules and coding mistakes don't cause you to accidentally upcode.
If you're at the bottom of the learning curve when it comes to medical billing codes, my About.com colleague, Trisha Torrey, has a great intro to medical billing codes on her Patient Empowerment site.† Check it out: "A Patient's Guide to Medical Billing Codes."
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If you've had a health insurance claim denial or a pre-authorization request denied, you need to find out why your health plan is refusing to pay. There are literally hundreds of reasons for a health insurance claim denial, and many are legitimate. However, a common reason for having a claim or pre-authorization request denied is a simple screw-up.
In "How Silly Mix-Ups Cause a Health Insurance Claim Denial," you'll learn how these screw-ups can happen so you can spot one when it happens to you. See specific examples and understand† how seemingly silly little things can have a big impact on your health care and your finances.
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Is your health plan refusing to pay for care that your doctor says you need? Does your health insurance reviewer say the health plan won't pay because the care isn't medically necessary? If so, you've received a medical necessity denial.
However, medical necessity denials don't always mean your health plan's claim reviewer or pre-authorization reviewer thinks you don't need the care. There are some reasons for a medical necessity denial that don't really have to do with whether or not you need the care.
Learn more about medical necessity denials, when they're really about what you need, and when they're not. "Why Does My Health Plan Say the Care I Need Isn't Necessary?"
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If you've gotten a health insurance claim denial or had a pre-authorization request refused, it can be frustrating and frightening. After all, you have health insurance so it'll help pay for your health care. What's the point of the health insurance if it refuses to pay when you need it the most?
Well, hold on there. Sometimes a denial means you need to fight, sometimes it doesn't. Before you can make an informed decision about whether or not to fight when your health plan won't pay, you need to understand why your health plan is refusing to pay.
Learn more about this in "Why Your Health Insurance Won't Pay for Your Health Care."
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The administration has issued guidance cutting some slack for those who were uninsured for the first part of 2014. †This will help many folks avoid the penalty for being uninsured if they signed up for health insurance a bit late.
First, some background information: You're supposed to pay a tax penalty, known as the individual shared responsibility payment, if you're uninsured. A bit of slack is built into the Affordable Care Act as it provides an automatic exemption from this penalty for anyone who was uninsured for a single period of less than three months. Those who are uninsured for three months or more were supposed to get hit with the penalty.
Originally, this meant you'd have to sign up for health insurance well in advance of the end of Obamacare open enrollment on March 31, 2014 to avoid the penalty. Since you'd need to have health insurance by March 1, 2014 to squeeze in under the three-month deadline, you would have had to sign up by February 15, 2014.
However, months ago the Obama administration issued guidance clarifying that anyone who signed up for health insurance on their state's health insurance exchange at any time during this year's open enrollment would be exempt from the penalty. This cut some extra slack to those who waited until the last day of open enrollment to sign up. Even though their health insurance won't kick in until May 1, 2014, they'll get an automatic exemption and won't have to pay the tax penalty for being uninsured from January 1-April 30, 2014.
Now, with the new guidance released this month, the administration is extending this automatic exemption to those who signed up for any type of minimum essential coverage health insurance as long as the coverage kicked in by May 1, 2014.
The nuance with this new rule-slackening is that you're not required to sign up on a health insurance exchange to avoid the penalty. If you got your health plan outside of the health insurance exchange, you'll still avoid the penalty. For example, if you started a new job and your health coverage kicked in by May 1, you'll get an automatic exemption from the penalty for the months you were uninsured between January 1 and April 30. If you signed up for Medicaid and it kicked in by May 1, you're safe from the penalty.
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There's lots of good information available about medical and insurance codes, but it's harder to find plain-language information about DRGs.
DRG stands for diagnostic related grouping. It's not a mystery secret code like the bar code on your grocery items. It's the payment system that Medicare uses to pay for the hospital stays of its beneficiaries. Increasingly, DRGs are also being used by private health insurance companies.
If you're confused about how Medicare pays for your hospitalization; what, exactly, a DRG is; or why you've been assigned a particular DRG, these resources will help.
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Business travelers get upgrades on hotel rooms, airline seats, and rental cars. Now, poor folks can get an upgrade on health insurance with the cost-sharing health insurance subsidy. Learn how this lesser-known health insurance subsidy works.
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If you're getting a health insurance subsidy to help you pay for health insurance, your eligibility was based on federal poverty level. Learn more about federal poverty level, including the three things you must know to use federal poverty guidelines with health insurance subsidies. Check out "Federal Poverty Level & Health Insurance."
Are you receiving the premium tax credit health insurance subsidy? Worried you'll have to pay all or part of it back next April 15th? You probably don't have hundreds or thousands of dollars in spare cash sitting around or you wouldn't be getting subsidized health insurance.
There are two techniques to avoid having to pay back any of your subsidy money. Learn about them in "Avoid Having to Pay Back Your Health Insurance Subsidy."
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