OIG’S VOLUNTARY COMPLIANCE TO MEDICAL BILLING COMPANIES

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OIGS VOLUNTARY COMPLIANCE TO MEDICAL BILLING
COMPANIES
Health care providers are relying on billing
companies to a greater degree in assisting them
in processing claims in accordance with
applicable statutes and regulations.
Additionally, health care professionals are
consulting with billing companies to provide
timely and accurate advice with regard to
reimbursement matters, as well as overall
business decision-making. As a result, the OIG
considers compliance program guidance to
third-party medical billing companies
particularly important in efforts to combat
health care fraud and abuse. Further, because
individual billing companies may support a
variety of providers with different specialties,
OIG recommend that billing companies coordinate
with their provider-clients in establishing
compliance responsibilities. OIG has identified
specific areas of third-party medical billing
company operations that may prove to be
vulnerable to fraud and abuse. The OIG guidance
directs billing companies to focus on the
following seventeen (17) risk areas, both in
their own and their clients operations
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OIGS VOLUNTARY COMPLIANCE TO MEDICAL BILLING
COMPANIES

• Billing for items or services not actually
  documented
• Unbundling
• Upcoding, such as for example, billing for a
  higher level of visit code when a lower level has
  been done
• Inappropriate balance billing
• Inadequate resolution of overpayments
• Lack of integrity in computer systems
• Computer software programs that encourage billing
  personnel to enter data in the fields indicating
  services were rendered that were not actually
  performed or documented
• Failure to maintain the confidentiality of
  information/records
• Knowing misuse of provider identification
  numbers, which result in improper billings
• Outpatient services rendered in connection with
  inpatient stays
• Duplicate billing in an attempt to gain duplicate
  payment
• Billing for discharge in lieu of transfer
• Failure to properly use modifiers
• Billing company incentives that violate the
  anti-kickback statute or other similar federal or
  state statute or regulation

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OIGS VOLUNTARY COMPLIANCE TO MEDICAL BILLING
COMPANIES

• 15. Joint ventures
• 16. Routine waiver of copayments and billing
  third-party insurance only and
• 17. Discounts and professional courtesy.
• To avoid above risk areas OIG suggest few
  recommendations. Although these recommendations
  include examples of effective policies, each
  billing company should develop its own specific
  policies tailored to fit its individual needs.
  The policies must create a mechanism for the
  billing or reimbursement staff to communicate
  effectively and accurately with the health care
  provider.
• Policies and procedures should
• Ensure that proper and timely documentation of
  all physician and other professional services is
  obtained prior to billing to ensure that only
  accurate and properly documented services are
  billed
• Emphasize that claims should be submitted only
  when appropriate documentation supports the
  claims and only when such documentation is
  maintained, appropriately organized in legible
  form and available for audit and review. The
  documentation, which may include patient records,
  should record the time spent in conducting the
  activity leading to the record entry and the
  identity of the individual providing the service

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OIGS VOLUNTARY COMPLIANCE TO MEDICAL BILLING
COMPANIES

• Indicate that the diagnosis and procedures
  reported on the reimbursement claim should be
  based on the medical record and other
  documentation, and that the documentation
  necessary for accurate code assignment should be
  available to coding staff at the time of coding.
  The HCFA Common Procedure Coding System (HCPCS),
  International Classification of Disease (ICD),
  Current Procedural Terminology (CPTTM), any other
  applicable code or revenue code(or successor
  code(s) ) used by the coding staff should
  accurately describe the service that was ordered
  by the physician
• Provide that the compensation for billing
  department coders and billing consultants should
  not provide any financial incentive to improperly
  upcode claims
• Establish and maintain a process for pre- and
  post-submission review of claims to ensure
  claims submitted for reimbursement accurately
  represent services provided, are supported by
  sufficient documentation and are in conformity
  with any applicable coverage criteria for
  reimbursement and

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OIGS VOLUNTARY COMPLIANCE TO MEDICAL BILLING
COMPANIES

• Obtain clarification from the provider when
  documentation is confusing or lacking adequate
  justification. Because coding for providers often
  involves the interpretation of medical diagnosis
  and other clinical data and documentation, a
  billing company may wish to contract with/assign
  a qualified physician to provide guidance to the
  coding staff regarding clinical issues.
  Procedures should be in place to access medical
  experts when necessary. Such procedures should
  allow for medical personnel to be available for
  guidance without interrupting or interfering with
  the quality of patient care.
• References
• Office of Inspector General (OIG), Federal
  Register / Vol. 63, No. 243, Third party PDF.
  Retrieved from https//oig.hhs.gov/fraud/docs/comp
  lianceguidance/thirdparty.pdf
• Brian Mahany (2016, November 15), Medical Billing
  Companies Can Be False Claim Targets. Retrieved
  from https//www.aapc.com/blog/36813-medical-billi
  ng-companies-can-be-false-claim-targets/