In a recent case in Georgia, the Grady Health System reached a settlement in a case for approximately 3 million dollars. Grady was sued by the state for allegedly using inaccurate medical coding to turn more of a profit. The Grady Health System and the State of Georgia have since reached a settlement for 2.95 million dollars and no admission of wrongdoing.

Cases like this are only becoming more common as tougher laws are being enacted to stop healthcare fraud. Under the Affordable Care Act (ACA) and the Health Insurance Portability and Accessibility Act (HIPAA), strict standards for medical coding and billing must be adopted to ensure that proper methods are being followed and patients are being protected.

Healthcare Fraud

One of the main goals of both the ACA and HIPAA is to help safeguard patients from healthcare and insurance fraud. This is accomplished through ensuring that all patients have access to affordable healthcare and through the implementation of stringent medical billing and coding standards. In the case of the Grady Health System, it was suggested that Grady did not follow proper coding standards, allegedly by inflating costs or inaccurately coding.

HIPAA, ACA, and Medical Billing

HIPAA and the ACA also set standards for the medical billing process. They mandate the use of a standard codex to be used by any healthcare provider taking any part in a public health program. The codex used for the purpose of standardizing the medical billing process is known as the Current Procedural Terminology (CPT).

The CPT is a list created and maintained by the American Medical Association (AMA) and refers to procedures and services rendered, rather than diagnoses, in order to standardize the way insurance companies are billed. Failure to adhere to these standards can lead to issues with how or if the healthcare provider is fully reimbursed for services and how much the services will cost the patient.

The Importance of Accurate Medical Billing

With the increasing amount of laws pertaining to healthcare and specifically medical billing, it is critical that healthcare providers are knowledgeable and up-to-date regarding coding standards. Failure to adequately adhere to the standards or properly code for services rendered has the potential to cost a firm millions of dollars.

For this reason, it is often helpful to turn to companies like Quest National Services that specialize in medical coding and billing. They will help ensure that businesses are compliant and educated when it comes to new laws and policies.