Medical Billing Compliance: What Healthcare Providers Need to Know

16 March 2023
Medical Billing Compliance

What is meant by medical billing compliance?

Adhering to the legal rules and regulations, which are pivotal for maintaining the safety and privacy of patient data, is referred to as Medical billing compliance. Being an integral part of the medical coding and billing process it must address the proactive compliance tasks in the medical billing industry.

What is Healthcare Compliance?

A well-organized plan, formulated with specific steps and called compliance elements, forms the foundation of healthcare compliance. Mainly, it aids in the prevention of fraud or in avoiding wastage. It is a consistent process that ensures that those proactive tasks within the healthcare organization are legal, ethical, and meet professional standards.

Healthcare Compliance’s Seven Core Elements:

The seven core elements of healthcare compliance are mentioned below:

• The written policies and procedures

• The compliance team and the compliance officer's designation

• Proper training and education among the organization's employees and compliance officer

• Excellent communication among the Medicare-Advantage-related contractors, the compliance officer, and the organization's employees.

• Enforcement of standards

• Internal auditing and monitoring, inclusive of risk assessment

• Standardized procedures to effectively respond instantly to the detection of offenses

Who can benefit from the Healthcare Compliance Programs?

Observing an efficient culture of compliance creates a strong base for your organization's legal and ethical behavior. An efficient healthcare compliance program can benefit several healthcare settings. The OIG can use its many free resources and help organizations by offering guidance to design a healthcare compliance program. Let us have a look at those various settings below:

• Hospitals

• Laboratories

• Physicians and their groups

• Durable Medical Equipment (DME) suppliers

• Home Health Providers

• Ambulance suppliers

• Third-party billing companies

• Pharmaceutical manufacturers

What is HIPAA Compliance?

HIPAA compliance refers to adhering to the various physical, technical, and administrative requirements of HIPAA (the Health Insurance Portability and Accountability Act). Those of which business associates and covered entities (health plans, clearing houses, or health care providers, for example) need to protect the Protected Health Information (PHI)'s integrity.

What are the main objectives of HIPAA regulations?

The primary objective of HIPAA Regulations is to uphold and protect the integrity of Protected Health Information (PHI). The following three are the main concerns:

• The Privacy Rule –for creating privacy standards of PHI.

• The Security Rule –ensures standardization of the electronically protected health information (ePHI)'s complete handling.

• The Breach Notification Rule –commands the business associates and the covered entities should instantly alert whichever parties get affected when their health information gets compromised.

What is meant by Billing and Coding Compliance?

The main focus of Billing and Coding Compliance is to audit and monitor carefully the relevant clinical documentation and the medical necessity for the various medical services rendered to the patients. Also, the same team must ensure compliance with all the applicable Federal and State Laws, policies, and various regulations leading to billing and coding.

Severe consequences occur due to billing and coding errors, leading to fraud allegations, high legal costs, and sometimes even criminal penalties and ruining the reputation. Sometimes, these errors are negligent. Yet failure to clearly understand the law or give expert compliance training to the staff cannot be taken as an excuse for the violations.

Why is Medical Billing Compliance important in Healthcare?

There is much to worry about when you manage a medical practice. More complexity arises in billing and coding as it gets challenging to pace with the constantly evolving laws, medical codes, and regulations. Even the most adroit practice needs help to comply with these changes. Sadly, we must accept that we may face adverse outcomes if we fail to be accurate and remain compliant in medical billing and coding.

Three significant reasons: for medical billing compliance.

• Financial Security for your business.

Your business may face severe financial consequences if the billing and coding need to be more accurate. The patient or the insurance company will not pay the total amount to your practice for the services rendered. At times, it might be a small deal at times as the amount could be pretty meager, but sometimes, the practices lose tens of thousands of dollars over a stipulated time. If your medical billing is not accurate and ends up being noncompliant, it causes the practices to be at more risk of receiving a lawsuit. You can quickly achieve compliance when a valid billing and coding protocol gets maintained and enjoy financial security, enjoying amplified healthy revenues.

• Security for your patients:

When a patient is at your practice, efficient and accurate medical coding is pivotal. It gets utilized for effortlessly pointing out and also documenting the entire diagnoses and treatments that got rendered. Whatever documentation gets done comprises a significant part of the patient's medical record. Hence it is paramount to keep it protected and ensure the data is accurate. The patient or their designated family member might require access to information such as their lab results, x-rays, or the prescribed medication details. There is a high risk to patient safety if the information shared is inaccurate, affecting future medical care quality and accuracy. An incorrect coding could quickly put the patient's health at risk, and they cannot tolerate it.

• Forecast the future of your practice:

You can be ensured of accurate billing to patients and insurance when your practice remains compliant with all the medical coding protocols. The future of your practice gets predicted when your billing is accurate, allowing you to make crucial decisions for your business and prepare your practice for remaining successful in the future.

BIS for your effective Medical Billing Compliance Solutions

Business Integrity Services has a proficient team of trained professionals who would gladly aid your organization in remaining medical billing compliant with our effective solutions. For more information on medical billing compliance solutions, please feel free to contact us.