Avoid HIPAA Violation, Billing Issues at Your Practice

I sometimes find myself on the consumer end of the healthcare issues on which I advise my clients. Each experience is a learning opportunity I try to share with them.  For instance, I recently received a bill from a practice in Massachusetts addressed to my 13 year old son. 

The bill outlined services provided by various different physicians, previous amounts paid and/or reimbursed by insurance (naming the insurer) and the amount due for services. There was nothing about the patient’s treatment in the past year that I could not tell by looking at this bill, including drugs injected and surgeries performed.  The problem was the patient was not my son, and I live in Chicago!

The bill had a contact number for the billing office and I immediately reached a billing supervisor. The supervisor (let’s call her Anne) could not find anyone by the name of my son in their entire system and denied the account number on the bill belonged to them. I insisted the bill came from their practice and faxed it over to her.    Anne promised to look into it and less than thirty minutes later left me a voicemail that informed me: “I did not need to worry about paying the bill” and “clearly it was just an error.”  My attempts to follow up have been unsuccessful.  Whether they discovered the reason for the error is unknown, but clearly they do not want to discuss it with me.

While some patients might have been concerned about the amount due, I am more focused on the identity theft. This was not a mix-up between practice patients with similar names or a common payer.  The name and address of my child appeared to be located from some national database. Was his social security number at risk? Did someone in the practice or from the billing company act fraudulently?  Was it a simple error? 

When a practice becomes aware of any billing issue, it needs to be addressed internally.  When the information comes from an outside party, the practice needs to be particularly careful of how they handle the matter.  Such calls can lead to evidence of mismanagement or even fraud.  Additionally, just handling the call properly can have an effect on the practice, no matter the reason for the call.  Mishandling a caller can lead to a disgruntled individual complaining to the state, the Office of Civil Rights (to report a HIPAA violation) or even posting something on Yelp about how they were treated by the practice. 

To protect your practice, consider the ways in which the above situation might be handled and how your staff should be trained:

1. Always thank callers for bringing something to your attention that has an effect on your practice or billing issues, even if you think it’s a simple or explainable error.

2. Consider a process to log reports of anomalies or events so as to track them.  This is important if different people handle calls, so as to spot patterns. This is the number one way my clients have spotted fraud by employees in the past!

3.  Don’t immediately call back with a non-answer to an issue raised. Plan to respond after you have time to investigate (even if you are not at liberty to provide a detailed explanation). This shows appreciation to the caller (who also took the time to alert the practice to an issue).

4. Actually investigate the matter at hand! The fact that a bill ends up in a random person’s hands in another state is a sign of a significant error. Find out how it happened to see if there is a bigger issue and take appropriate action against those responsible if policy violations occurred.

5. Be prepared to handle the situation once you know the facts: Is this a HIPAA breach to be addressed? Is this a case of fraud? Does counsel need to be involved? Make sure your practice has appropriate policies and procedures in place.

Every experience should be one from which a practice can learn.  Mistakes can help improve a practice’s performance or reveal issues of which it is not aware.  Make sure your practice is set up to handle situations that arise in a way that benefits the practice and its reputation.