Medical Billing Compliance
People entrusted with protected information must know exactly what to do and what not to do when it
comes to medical records and confidentiality rules. The medical records must be safeguarded and all security
policies must be strictly adhered to, whether in an office, or when working from home. Today, health care providers
rely on Medical Billing Companies and medical research continually leads to new discoveries and new discoveries.
Medical billers, just like their medical coding colleagues, must be aware of new approaches and techniques and
understand these when submitting a claim. This can be accomplished by medical billers remaining actively involved
and partake in continuing education and workshops for medical billers and coders.
Being Accurate and Precise
One of the keys to receiving reimbursement is proving medical necessity. To accurately
post a claim, medical billers must be able to scrutinize all data and documentation in the patient's record and
show that services were justified and necessary. By carefully reviewing all entries and documentation in a
patient's chart they compare the ICD-9-CM codes for diagnoses and document the medical necessity of all further
treatments that followed. Being accurate and precise in this particular skill is key to timely reimbursement, but
also key to keeping overhead cost down, and a steady cash flow for the practice. Naturally, any practicing health
care provider that has a good medical biller will keep them, since it saves them many headaches and worries, and
ensures that they are getting paid.
Medical Billing Code of Conduct and Compliance
By Steven M. Verno, CMBS, CEMCS, CMSCS
These are some basic principles of the medical billing code of conduct:
1. Be honest and ethical. Under no circumstances will any and all information entrusted to an ABC Medical
Billing Company employee or consultant be used for illicit, unethical, or illegal means.
2. Obey the laws. If at anytime an employee is uncertain about State/Federal laws or applicable regulations have
jurisdiction over any and all information entrusted to the ABC Medical Billing Company, the employee is required to
seek assistance from their immediate supervisors.
3. Every employee or consultant must be completely truthful and have supporting documentation to support any
statement or claim.
4. Medical claims must be true, accurate, complete, and filed in accordance with current applicable
State/Federal Laws, and health insurance company claims guidelines. In the event that there may be doubt as to the
truthfulness of patient demographic and health insurance information received from the provider, the information
should be verified for accuracy prior to the submission of the claim.
a. Whether or not the member belongs to an HMO
b. The sponsor of the health care coverage
c. If the carrier is due to workers Compensation or a personal injury:
(1) The name of the employer providing health care coverage
(2) The date the injury was reported to the workers compensation carrier.
(3) The name of the adjustor and the claim number (Workers Comp or Auto Claim).
(4) Whether the patient has hired the services of an attorney (Personal Injury)
d. If the carrier is primary or secondary
4. Under NO circumstances will any claim be submitted, either by paper, or electronic means without having the
information 100% verified to contain NO errors.
5. Every employee or consultant must ensure that patients' private, financial, and personal health information
(HPI) is secure and held in strict confidence from unauthorized entities, and individuals.
6. All complaints must be taken seriously, and non-compliant practices are addressed and corrected in an
To ensure that the medical billing company is prepared
to address its compliance obligations here is a downloadable Billing Complaince Manual compiled by Steven M. Verno, CMBS, CEMCS, CMSCS.
CMS and OIG
Another important consideration in the medical coding and medical billing realm concern CMS
(previously HCFA) and the Office of Inspector General (OIG) regarding health care provider's in-house compliance
plan. The purpose of the compliance plan is to establish voluntary compliance programs that meet all HIPAA
regulations. Every health care provider participating in federal programs like Medicare and Medicaid should eagerly
embrace these compliance plans and help their medical coding and billing staff members to learn, understand, and
adhere to these rules.