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Ways to Ensure You are Not Accidentally Committing Insurance Fraud

Believe it or not, it is quite easy to commit insurance fraud accidentally. Unfortunately, there are plenty of people that intentionally attempt (and succeed) at defrauding Medicare, Medicaid, or private insurance companies. It is one of the reasons health care costs rise every year. However, you can also commit insurance fraud without knowing that you are committing fraud.

In this blog we are going to take you through some checks and balances that will serve as guideposts to make sure that you are operating in an ethical and legal manner with respect to your insurance billing processes.

Review Your Insurance Contracts and Provider Manuals

One of the best ways to ensure that you are not committing insurance fraud is to carefully review your insurance contracts. You sign a contract with an insurance company when you become an in-network provider. This contract contains critical information about your legal obligations and relationship with the insurance company.

Within the contract with the insurance company you are likely to find information about contract termination, how long your contract is going to last, what your responsibilities are to the insurance company, what your responsibilities are in submitting claims and collecting from your clients, and any other information related to your relationship with the insurance company.

Additionally, the document that seems to be overlooked more often than any other document when taking insurance is the provider handbook. The provider handbook is a document that every insurance company has including Medicare and Medicaid that helps to clarify any procedural questions that you may have.

The provider handbook provides information such as provider consultant contact information, claims addresses, dispute procedure, appeals procedure, and many other info items that will make your relationship with the insurance company flow.

Oftentimes insurance companies do not provide a lot of marketing around the provider handbook and it is up to the provider or the office staff of your practice to find a handbook, read it, understand it, and apply the procedure within the handbook. The provider handbook is a guiding and living document that will help your practice run smoother and ensure that you do not commit insurance fraud.

If you are a solo provider it is highly recommended and encouraged that you read through the provider handbook for each insurance company that you are in network with. If you have an office staff that handles billing then you will want to require them to read and understand the provider handbook so they are familiar with the procedures with each insurance company.

Review and Audit Your Claims Before Submission

One really simple way that you can ensure that you are not committing insurance fraud is by reviewing and auditing your claims before they are submitted to the insurance company. There could be a lot of mistakes that are made between a session being completed and the submission of a claim. Most electronic health records require the rendering provider fill out much of the information before a claim is submitted.

Most therapists try their best to do the right thing but sometimes mistakes are made accidentally before a claim is submitted. One action item that we would recommend is implementing a procedure within your administrative processes that has at least one person review the claims before they are submitted.

One technological benefit that is an advent of the 21st-century is that of the clearinghouse. The clearinghouse is the digital tool used to scrub a claim of any administrative errors before they are submitted to the insurance company. Most of the time the clearinghouse does a good job of catching most mistakes however there are times that the clearinghouse does not catch any contractual obligations with the insurance company. This is where you will need to have a sophisticated auditing process to review claims before they are submitted.

Charge Your Clients Based on the Explanation of Benefits

Therapists and other mental healthcare providers have gotten into the habit of charging clients based on eligibility and benefits checks. The risk with doing that is that eligibility and benefits checks are wrong 30% of the time. There are a lot of reasons why eligibility and benefits checks are wrong that often but the main point of application here is that you charge your clients based on the explanation of benefits and not the eligibility and benefits check.

There are times that providers will charge clients based on the eligibility and benefits checks, but they will charge on the wrong amount or they will not charge them at all which is in direct violation of the providers contract with the insurance company. This is an area where providers can get into a lot of trouble because a client can file a dispute with the insurance company and with the insurance commissioner. This is not something that one would want to take lightly.

Generally speaking, you would be in a much safer position to charge the client based on the explanation of benefits. The complication with doing that is that the moment the client walks out the door you decrease the likelihood of getting paid at all from the client unless they are a repeat client that you trust. Therefore, most therapists and mental health professionals do their best to charge the client directly after the session.

If you want to continue to charge your clients directly after the session, you may want to consider lowering the amount of insurance companies that you take so that you know precisely how much to charge each client. The other trick of the trade is that you can keep a card on file and charge the client as soon as the explanation of benefits is received and posted.


In summary, we at Practice Solutions want to make sure that you are not committing accidental insurance fraud or purposeful insurance fraud. We routinely review claims that we submit and in almost all cases we review every claim before they are submitted. We regularly advise our clients on compliance related items and ensure that your practice is around for the long-haul. We value you and the work that you were doing in the mental healthcare industry and want to ensure that you are operating as cleanly as possible.

If there are ever any topics that you’d like to hear more about feel free to reach out to us and we will do some research and publish a blog around that topic.

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