Tables of Content
1. Unbundling Explained
Unbundling is an error in the medical Billing, at times also for the purpose of medical billing fraud. In the process of unbundling multi-step procedures which are performed as a whole are broken down into simpler steps to list them separately. This means that instead of a one coded procedure, several billing codes are used for the same procedure. Using multiple steps during the billing creates a greater amount of reimbursement for the services.
A Current Procedural Terminology (CPT) code is assigned to each medical service and procedure for the purposes of standardization in medical bills. A basic CPT code is a five-digit code which describes the service provided. Irresponsible use of these codes is responsible for unbundling.
At times, unbundling is also termed as “fragmentation”. This is in reference to the practice that a procedure which can be billed under a single code is fragmented or broken down into multiple codes for a larger bill amount.
2. Reasons For Unbundling
There can be multiple reasons for an unbundling, ranging from honest errors and machine errors to more sinister criminal intent. Some of the commonest reasons leading to unbundling are listed below-
Lack Of Understanding/ Knowledge: This can be considered as the most common reason responsible for medical billing errors. If the coder who is responsible for the billing does not have adequate knowledge about the Current Procedural Terminology System, mistakes are bound to happen. Rookies often misread the code due to a lack of experience or knowledge.
False Assumptions: Coders are not present when a medical practitioner is providing healthcare services. At times, they may assume that two services were availed separately instead of simultaneously. In this case, coders do not consider making a package or bundling the two services together. This leads to unbundling.
Criminal Intent: Overcharging for the services provided is a white collar crime. This common fraud may be performed by coders and medical offices illegally. Purposely using unbundling of medical billing will lead to a greater amount of bill. This intentional unbundling of the services will lead to a considerable increase in their profits. Although not so common now, deliberate unbundling medical billing cannot be completely ruled out. Intentional unbundling can always adversely affect the patients and their financial status.
Errors: Simple machine errors or software malfunctions can also create unbundling in a medical billing. In this case also patients would be overcharged but it would be unintentional.
3. How To Avoid Unbundling
Medical practitioners, medical care providers, healthcare institutions and consumers; all face the negative aspects of unbundling. While the monetary burden initially falls upon the consumer, long-term errors may lead to legal action against the institutions and the providers. Keeping in view the plethora of negative consequences, avoiding unbundling is the need. A few easy and practical ways include-
Hire knowledgeable and experienced coders. Have regular workshops to keep coders updated about new guidelines of CPT.
Keep the medical records legible and easily understandable. This will lead to a lowering in assumptious unbundling.
Keep the softwares and the machines updated to avoid errors.
Use timely services of medical billing experts to review and help enhance the billing process.
4. Examples Of Unbundling
Inappropriate reporting of procedures which leads to unbundling will lead to a greater financial load on the consumer. Two procedures which are performed simultaneously should be reported as such and not as two separate codes.
Examples of such incorrect coding is-
If a biopsy is performed concurrently with an endoscopy, the code to be used would be for 'endoscopy with biopsy' instead of two separate codes for 'diagnostic endoscopy' and 'confirmatory biopsy'.
If bilateral mammography is being performed, the code to be used should be as such 'bilateral mammography' instead of two billings for 'unilateral mammography'.
In a routine surgical procedure, billing of 'incision' and 'suturing' in different codes would be fragmentation or unbundling.
5. Legal Aspects To Report Medical Unbundling
When medical unbundling is suspected, it can be reported under The False Claims Act for further legal action. The claimee needs to obtain sufficient evidence that a medical bill was excessive to prove unbundling. A history of excessive unreasonable bills by the care provider would also work in the favor of the claimee.
Medical billing experts are those whose job itslef is to look for and prevent billing errors and frauds. They look for proof of unbundling in medical billings. They compare the medical records alongside the medical bills to determine whether or not the separately coded procedures were performed at the same time. Medical billing experts are also very helpful in claimant cases as they help lawyers by identifying unreasonable and fraud billings.
The False Claims Act which was enforced allows employees and others who may possess the knowledge about an ongoing healthcare fraud a way to report it safely.
Whistleblowers can file a “qui tam” lawsuit along with a lawyer which will lead to a government investigation. After proper investigations of the allegations and complaints in the lawsuit, the government will decide the further course of action. It can either intervene in or join lawsuits and pursue litigation. Even if the government decides not to intervene, the whistleblowers can go forth with litigation on their own and recover funds. Those who file the lawsuits are protected under the provisions of the False Claims Act. It prohibits retaliation against whistleblowers.
Whistleblowers also have a monetary gain as they can receive from 15 to 30 percent of the amount recovered from the lawsuit.
6. Conclusion
Medical unbundling is a billing error which may either be an honest mistake or a Intentional sabotage. Whichever may be the case, the financial load of the error falls unto the consumer. One should reamin vigilant and thoroughly check the medical bill provided by the healthcare institutions.
In case of doubt, professionals such as medical billing solutions would be of help to determine whether or not one has fallen prey to unbundling. If present, a legal litigation can be filed under which the money lost to the malpractice can be recovered.