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Medical Billing Compliance

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Today, healthcare providers rely on Medical Billing Companies such as ABC Billing Company to provide claims submissions in a timely manner as required by the client’s (provider’s) Health Insurance Contract, Applicable State and/or Federal Health Insurance Laws, or the Patient’s Health Benefit Manual/Summary Plan Description.

Medical research continually leads to new discoveries, and naturally, new discoveries allow for new techniques of performing the same treatment procedure to treat patients. Medical billers, just like their medical coding colleagues, must be aware of new approaches and techniques and understand these when submitting a claim.

Although health care providers must also stay current on new discoveries and trends, they have no time to devote themselves to staying abreast with rules in the health care insurance and claims management sector. This can be accomplished by medical billers remaining actively involved and partake in continuing education and workshops for medical billers and coders.

Certified Billing and Coding Specialist (CBCS)

Unlock the secret of thousands of nationally recognized medical billing and coding professionals across the USA! HOW did they do it?

Now that you understand the ins- and outs of the medical coding and billing profession better, you also realize the IMPORTANCE of nationally recognized CERTIFICATIONS.

Showing Medical Necessity

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

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.

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.

Code of Conduct and Compliance
Written by Steven M. Verno, CMBS, CEMCS, CMSCS.
Reprinted with author's expressed permission.

These are some basic principles of the ABC Medical Billing Company 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 appropriate manner.