Medical Billing

How To Manage Ethical Conflicts In Medical Billing

When patients get healthcare services from any healthcare provider, they receive accurate and fair medical bills. This shows the trust of the patients in the healthcare institute. In return, the healthcare institute also must meet all the expectations of their patients and work within the legal and ethical range of the medical billing process. There are also chances of unintentional mistakes in the billing process, but healthcare institutes should take great care to avoid errors.

Ethical conflicts have been known for a long time in the billing process due to the medical provider’s greed and fraud. Ethical conflicts deteriorate the institute’s reputation and trust issues develop between the patients and the providers. Overcharging or coding errors all come under ethical violation, which should be dealt with seriously by the regulatory authorities to protect patients from financial burdens. Many ways can be helpful to deal with this condition. Training of the billing staff, scrutiny, audits, and implementation of punishments can be helpful in this regard.

In this article, we will discuss the major ethical conflicts and how healthcare institutes should deal with the ethical conflicts. We will also learn the major issues that arise in the healthcare institute due to ethical conflicts.

Major Ethical Conflicts in Medical Billing

Major Ethical Conflicts in Medical Billing

1.  Overbilling and Underbilling

Sometimes, providers, for their financial benefits, charge more than the fair price for the healthcare service to the patient. This is a very common and major unethical practice that puts a financial burden on the patients for a service they have never received. Overbilling distorts the trust between the healthcare institute and patients. On the contrary, underbilling seems less unethical, but it can put a major financial strain on the providers and healthcare organizations. Medical billing staff should make the medical bills with full care and attention to make the organization financially stable.

2.  Upcoding and Unbundling

Upcoding is to assign higher billing codes for the service than what was performed. Another medical service is mentioned on the medical bills, which have higher reimbursement rates. This provides financial benefits to the providers. Patients are mostly unable to understand the medical codes, and they get the medical bills for the false medical facilities, and they pay the bill without even understanding it. While unbundling splits the medical service into various segments and charges for each segment separately, which makes up a large bill.

3.  A Breach in Data Privacy

It is mentioned in many healthcare laws and policies that privacy and confidentiality is the foremost priority of the provider. This involves sensitive data like personal and medical information about their ailment. It is only allowed to provide the information with the permission of patients or the court. However, some staff members leak the information for their benefit or reasons, which is unethical.

4.  Surprise Bills and Kickbacks

The medical practitioners must discuss all the situation and treatment expenses with the patients before starting the treatment. But sometimes, doctors provide expensive medical expenses without negotiation, and patients get a surprise medical bill. In case of the absence of in-network physicians, treatment is provided by the out-of-network doctor without informing the patients. This adds a huge amount to the bill.

Getting benefits or privileges from outside entities like medical labs or pharmaceutical companies in exchange for prescribing their products is also discouraged. This also comes under ethical conflicts.

Strategies for Managing Ethical Conflicts

Strategies for Managing Ethical Conflicts

    Training and Education

It is seen that most billing staff members need to learn the exact laws and policies regarding the medical billing process, and they make mistakes that come under unethical practice. Therefore, it is recommended that timely training for the staff should be provided to teach them about policies and laws like the False Claim Act, HIPAA, and ACA. This will give them a true sense of medical billing, and they can also remain updated with the new policies.

    Emphasize Ethical Leadership

People always follow the path of their leader, and their leader can only encourage them to practice legal and fair medical billing. Education should be given to the big names of the healthcare institute to show legitimate actions to attract the people to do the same. Leaders should encourage the importance of transparency, accountability, and ethical decision-making. This can decrease the ratio of ethical conflicts in the medical bills.

    Monitor Billing Practice

There should be a monitoring cell in every healthcare institute to review the activities of billing staff. They should detect the irregularities in the billing process, if any. They should look for common billing mistakes or frauds while considering current fraud trends. The billing staff will also work smoothly because they know there will be an audit of their activities.

    Ensuring Transparency in Bills

To maintain the trust of the patients and insurance companies, healthcare institutes should ensure fair and accurate medical bills. Transparency can be achieved by checking the patients’ credentials before starting the treatment. Detailed documentation and communication with the patients also serve in the formation of transparent medical bills. It should be checked that all the medical codes align with the medical facilities provided.

    Addressing Ethical Conflicts

A culture of feedback and confidential reporting should be developed in every institute where members of the organization can come fearlessly and report suspected ethical conflicts. A monitoring committee should handle these cases fully by evaluating and analyzing the data. If any breach of law or policy is found, then it should be dealt with without any favors.

    Regular Audits

Audits are the best practice to track all the financial records and identify the irregularities that can give the information of errors or mistakes. The audit team of a healthcare organization should analyze the medical bills after a specific time to check the discrepancies in the billing process. This helps to detect cases of fraud or unethical practices. The cases of ethical conflicts should be dealt with timely to save the institute’s reputation.

    Implementation of Technology

Technology is improving the output in each organization with a minimal margin of error, and this can be used in the medical billing processes to detect false claims and irregularities. Technologies like AI, blockchain, big data, and electronic health records help in analyzing medical bills and identifying unethical practices. Technology does the work for months and days, and it also has precise results.

    Scrutiny and Accountability

Identifying the errors or unethical mistakes in the medical bills is not merely enough; there should be scrutiny of the staff to detect the person or persons behind the ethical conflicts. It is very important to find the responsible persons behind ethical conflicts and make them accountable for their deeds to discourage more such acts. This will set an example for the other staff members.


Medical billing is a complex and sensitive process, and there is a need for great attention and care to avoid any ethical conflicts or fraud. To maintain the reputation and integrity of the organization, it is necessary to manage ethical conflicts by taking crucial and good measures. Charging more patients for medical service, seeking privileges from outside entities, and leaking patients’ data are the main and common ethical conflicts that harm organizations and patients. Charging for a facility that is not provided to the patient is also unethical, and it should be dealt with accordingly. Surprise billing of unnecessary services or out-of-network treatment without the patient’s consent also stresses the patients. All the above-mentioned ethical conflicts can be managed by training and educating the billing staff, emphasizing ethical leadership, and monitoring billing practices through timely audits. Peer reviews can also contribute to identifying ethical conflicts. Healthcare organizations should use the technology to detect ethical conflicts and make the billing process efficient and fast.