Evaluating Compliance Strategies
HCR/220

Compliant billing involves certain steps in order to properly bill a patient and receive any monies owed for those services performed. First step is for the doctor to fill out and sign any and all forms at the end of a patient’s visit. The next step is to post the transactions made along with the proper medical codes from a patient’s appointment into the practice management program which leads to the claims being filed. Payers then need to make sure that the services performed along with the diagnosis must show that it was medically necessary services. The billers also need to know the proper rules and guidelines put forth by a patient’s insurance company. Because medical insurance companies constantly change their policies, the insurance specialist rely on the payer’s website or may regular communicate with a representative of the payer. The correct coding initiative controls improper coding that would result in improper payments for Medicare claims. The CCI also monitors billing of any services that Medicare believes cannot be performed together. The CCI also requires doctors to tell about the most extensive service that was performed and not the revealing of both the extensive and limited services. Finally the CCI also tests for unbundling.
Many mistakes can be made while billing/coding a patient. Some of those mistakes are: billing invalid/outdated codes, coding without the correct forms, truncated coding; using codes that are not specific, assumption coding; coding services that were not actually performed, and billing for uncovered services performed by a doctor. If any of these mistakes happen, it can cause delay in payment to the correct parties as well as a possible rejected claim. Legal problems could also surface if any of the coded or billed services were not actually performed. This could lead to the staff of the doctor or medical facility being implicated in a case of fraud.
Payer audits are performed to make sure that billing compliance is being adhered too. Internal audits help a practice keep the errors within the billing and coding process down so that any and all claims will not be rejected. The audit also helps to recognize any problems, offers or suggests continual training, and review payer feedback. Doctors’ have set fees that are set up to let other providers know what they would charge for a specific procedure or service. This set fee chart is based on two methods: charge-based or resource-based. Charges based are fees that most providers use to charge for services. Resource-based fees are built by comparing three factors: difficulty of the service performed by the medical professional, how much overhead the service involves, and any risk to the patient and medical professional. Both these fee structures are based off the geographical location of the medical professional. Payers use the followed payment methods: allowed charges, contacted fees schedules, or capitation. I am a fan of the contracted fees method. This reminds me of a PPO plan. There is a set amount that is paid for a service that a patient receives from a medical professional. To me, this is a good method. There are not any surprises when it comes to the fees that the payer and the patient have to pay for the services rendered. If I had insurance, this would be the method that I would want. Unfortunately, many of us cannot afford to keep up the payments for insurance, so many of us go without. The medical coding process, the doctors involved, and the payer fees are all related to the compliance process because each named has to adhere to a certain set of rules. Medical coding has to adhere to all government rules and guidelines along with all other rules and regulations to not only protect themselves but the patients. The doctors and all other medical staffers have a code of ethics that needs to be followed to not only protect themselves but their patients. The payer fees also have a bunch of rules and regulations that need to be followed in order to protect them and all other involved. All these areas need these rules to avoid any legal problems such as lawsuits or fraud.
Compliance billing is crucial to the healthcare industry. Compliance is needed to protect the medical professional as well as the patient and payers. The compliance ensures that all proper rules and regulations are followed especially in billing and coding. Many people do not seem to understand that miss coding or under coding can cause more than just legal problems; it can result in the loss of the medical licensing. Also improper coding of bills can also result in rejected claims and delays in reimbursement.

Resource
Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd Ed.). Boston, MA: McGraw-Hill.