We hold deeply to the belief that most physicians are fair and honest in their billing practices.  This is not just a wishful thought, but comes from doing the billing and associated compliance audits on hundreds of physicians over the years.

Some providers fail compliance audits not because they are cheating, but because they have either fallen into erroneous habits or are just overwhelmed by the coding requirements. This process and structure couldn't be more complex if you locked up a bunch of mad scientists and asked them to wreak havoc on the American healthcare system.  Oh wait, ICD-10 is coming.  I guess it can get more complex.

But there are some cheaters out there, physicians who bill fraudulently not out of bad habit or a lack of understanding, but from malice.  They give the other 700,000 or more physicians a bad name.

Now comes news that Medicare has developed a complex predictive modeling tool that will be used to identify potential fraudulent billers.

If you are a cheating biller and are new to the concept of predictive modeling, here is your primer:  Medicare has some very sophisticated software that can handle giant amounts of data.  They are going to wash all of your claims through this before paying your claims.  The software is very smart and will flag any billing patterns that are suspect.  That will trigger a deep dive into your billing practices.  This software will know more about how you bill than you do.

This is good news for the ethical majority.  It will separate the bad apples from the rest.

But if you are in this group, here is your warning.  If your billing practices are flawed because of those bad habits or lack of education we mentioned above, we have bad news.  The software does not consider your intent or the cause of your billing errors.  It just looks at the facts.  You might win out in the review process, but it will be time consuming and painful.

Do yourself a favor.  Get your practices, your knowledge, and your billing processes up to speed.  Big Brother is watching, now closer than ever.