Compliances for Medical Billing Companies

Before you send out that first claim for federal or state reimbursement of health care services, you'd better be certain that you understand the federal and state issues pertaining to compliances for medical billing companies as established by the Office of Inspector General (OIG).

What are the issues related to compliance? The OIG along with the Health Care Financing Administration is taking steps to combat fraud and abuse surrounding reimbursement for health care services funded under Medicare and Medicaid. In an attempt to reduce and eliminate fraud and abuse issues in billing, OIG has set forth a seven point voluntary compliance plan to be adopted by medical billing companies.

Though it is voluntary to have a plan in place, it is wise to do so. Let's say that your medical billing company mistakenly sends duplicate or inaccurate claims to Medicare. If OIG investigate this situation as a case of fraud and abuse then having a voluntary compliance plan in place would show an effort of “good faith” to comply which could be very helpful if an investigation were to take place. Having a compliance plan demonstrates not only that you are working in a professional, legal and ethical manner but also can help reduce your liability in the circumstance that a fraud or abuse charge is filed against your business.

Examples of fraud include billing for services under the name of a deceased individual or for services never provided to a patient. Examples of abuse might include getting a kick back from referring agencies, over billing or billing for services that were not medically necessary.

Consequences of Poor Compliance for Medical Billing Companies

If a situation of fraud or abuse is revealed, any individual found guilty faces civil, criminal and administrative sanctions. For false claims, penalties can range from $5,000 to $10,000 and an assessment of three times the damages. Administrative sanctions can go as high as $10,000 civil monetary penalty per line on a false claim. Violation of kick back laws can result in both fines and imprisonment up to 10 years. That is why it's necessary to have a compliance procedure for medical billing companies.

OIG recognizes that medical billing companies vary greatly in size and in range of services offered so no standard compliance program is required. To learn more about the areas which need to be addressed in a compliance plan, visit the OIG website at www.oig.hhs.gov

Medical Coding Nexus, conceptualized in Feb, 2005, is an online portal which provides up-to-date, pertinent information about medical coding and billing. Copyright @2005 Honlyn Limited All Rights Reserved

In no event shall Medical Coding Nexus be liable to anyone for any inaccuracies, errors or omissions with respect to the information for any damage arising therefrom or occasioned thereby, or for the results obtained from the use of the information. By accessing this site , you are agreeing to the terms of use .