Medical Billing Compliance Program

One of the most common ways for providers and healthcare organizations to run afoul is to incorrectly or illegally bill and code for services or supplies. No matter the intent, noncompliance in medical billing can have severe consequences. This article discusses the issues related to medical billing compliance policy and the steps for providers to maintain financial integrity and adherence to all requirements.

Medical billing compliance ensures that providers and administrators engage in ethical and accurate billing practices. The regulations surrounding medical billing compliance policy come from:

Failure to comply with medical billing compliance regulations can result in:

  • Fines, penalties, imprisonment, or the loss of licensure
  • Allegations of abuse and fraud
  • Lost revenue
  • Civil lawsuits
  • Denials of Medicare, Medicaid, or private insurance claims
  • Loss of community trust and reputation

Even unintentional billing and coding errors create administrative inefficiencies and compromise the quality of patient care. It pays to know the law and avoid temptations to cut corners.

Steps for Staying Compliant in Medical Billing

The medical billing process can be complex at times. Still, administrators and providers must stay abreast of all applicable laws concerning the coding and billing of supplies and services. The following practices help healthcare organizations uphold compliance and streamline administrative processes.

Maintain a Medical Billing Compliance Program

A healthcare organization should establish a medical billing compliance program defining all policies and procedures for identifying, reporting, correcting, and preventing legal or ethical violations. This program should incorporate the following elements:

  • Compliance training for personnel at all levels
  • A regular schedule of monitoring and auditing of billing and coding practices
  • Quality assessments of clinical documentation
  • Transparent processes and protocols for reporting and correcting violations

Perform Periodic Billing and Coding Audits

As one of the hallmarks of a thorough compliance program, billing and coding audits allow administrators to identify mistakes before the government, insurance payers, or other parties discover them. When auditing claims, medical records, and financial documentation, it is essential to incorporate guidance based on the following questions:

  • Are all codes for services and supplies correct?
  • Are the claims accurate and complete?
  • Are there any missing supportive documents or records?
  • Did billing occur in an appropriate amount of time?
  • Do claims adhere to the applicable state and federal regulations?
  • Did providers or other personnel follow up promptly on any denied claims?

If an organization does not have the trained or qualified individuals to conduct an audit, it is advisable to hire external auditors. Compliance audits conducted by outside individuals can ensure accuracy and objectivity regardless of staff expertise.

Respond Promptly to Claim Denials

The claim denial rate has increased to about 20% within the past five years. Many medical bills are unpaid because providers do not promptly follow up on claim denials. This mistake resulted in millions of dollars in lost revenue for hospitals.

Because many denied claims can be recovered, providers need to follow up within the window of appeal or before the deadline outlined in the insurance payer contract. Doing so makes it possible to identify errors that can be corrected, allowing for timely resubmission of claims.

Conduct Regular Reviews of Healthcare Payer Contracts

Because of the complex legal language of most payer contracts, it is easy to make billing mistakes. This is why a regular review of these contracts is essential so that providers and administrators can clear up uncertainties in the terms or conditions, remain compliant, and ensure the payer is engaging in fair practices.

In addition to reading the fine print, a careful review includes checking language regarding the following elements:

  • Definitions of key terms, such as medical necessity
  • Dispute resolution protocols
  • Fee schedules
  • Network requirements

Partner with a Healthcare Compliance Company

Few healthcare organizations have the expertise to understand the many billing compliance regulations that constantly change. When leveraging the knowledge and experience of a healthcare compliance company, providers can reduce their risk of medical billing noncompliance and errors.

These companies can also help healthcare organizations stay on top of regulatory updates and foster cultures of ethical behavior and accountability. Partnering with such a company can provide access to tracking software and platforms, training, support for HIPAA, OSHA, and other laws, and assistance with compliance-related tracking and reporting. Another benefit is getting compliance program guidance for third-party medical billing companies.

Contact Compliancy Group today to learn how they empower providers and administrators to meet their billing compliance obligations, improve their work processes, and find solutions to common medical billing issues.

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