HEALTHCARE COMPLIANCE II Please answer the following 4 questions Thank you! 1. What are the reasons that health care providers contract with third-party b



Please answer the following 4 questions Thank you!

1. What are the reasons that health care providers contract with third-party billing companies to submit their claims for reimbursement from payors such as Medicare?

2. The compliance concerns of the billing companies are intertwined with those of its provider-clients. Those clients can create problems that lead to legal liability for the billing companies. How can the companies reconcile this potential conflict between them and their clients?

3. List five benefits that billing companies receive from operating a good compliance program. (just listing is fine).

4. The policies and procedures in a mandatory compliance program should address those areas of company operations that are most vulnerable to misconduct leading to fraud and abuse. These are the company’s“risk areas.” There are over 20 of them. Identify five and explain them.

Chapter 21

Third Party Billing Companies

Learning Objectives

Billing companies in the provider payment process

Compliance program benefits for a billing company

7 basic elements of a compliance program

High risk areas for billing companies

Duties of the compliance officer & committee

Curriculum for a compliance training course

Learning Objectives

Lines of communication between CO and employees

Disciplinary action against non-compliant employees

Importance of compliance monitoring

Options in handling misconduct & non-compliance


Many health care providers have chosen to outsource the tedious, complex billing procedures to third party firms that specialize in preparing accurate claims, submitting them, and following through to final payment.

The largest volume of fraud and abuse complaints, violations, and convictions stem from the filing of claims for reimbursement.

The problems can arise whether the billing activities are performed in-house by the provider or outsourced to a third party.

Benefits of a Compliance Program (I)

More likely compliance with laws, payor policies, and internal guidelines

Better medical record documentation

Greater cooperation between providers and those processing health information

React faster to employee compliance concerns

Respond faster to compliance problems

Demonstrates commitment to ethical, responsible corporate conduct

Benefits of a Compliance Program (II)

Assess employee/contractor fraud-related behavior

Identify & prevent illegal, non-compliant conduct

Central source for information on fraud issues

Encourages employees to report compliance problems

Thorough investigation of possible misconduct

Improve relationship with Medicare contractor

Reduced exposure to criminal and civil penalties

Basic Compliance Program Elements

Written standards, policies, and procedures

Compliance Officer and Compliance Committee

Compliance training

Open lines of communication

Disciplinary action to enforce compliance

Monitoring compliance performance

Responding to violations and taking corrective action

Written Standards, Policies, and Procedures

Standards of Conduct

Policies and procedures for high risk areas

OIG-identified list of 17 billing company risk areas

Additional 7 risk areas regarding coding services

Special emphasis on these areas:

Claims submission process

Credit balances

Data systems integrity

Records retention system


Compliance Officer and Compliance Committee

Compliance Officer – full-time job, report to CEO & governing board, conduct inquiries, and review compliance-related evidence

Duties of the Compliance Officer

Compliance Committee – composition

Duties of the Compliance Committee

Compliance Training

Train employees to follow the standards, policies, and procedures

Frequency and focus of training sessions

Curriculum for general training session

Training as a condition of employment

Emphasis on marketing & financial personnel

Variety of teaching methods employed

Open Lines of Communication

Between Compliance Officer and employees

To report compliance problems or ask questions

Several different communication paths available

Anonymous reporting and no retaliation

Document all reports and subsequent investigation

Disciplinary Action to Enforce Compliance

Imposed on any persons who fail to comply

Detailed procedure for administering discipline

Range of actions depending on culpability

Fair and equitable, appropriate and predictable

Background checks on new hires

Screen for convictions and debarment

Dealing with third party agents

Monitoring Compliance Performance

Both compliance program rules and avoidance of legal and payor problems

Extent and frequency of monitoring

Embedded in organization’s routine operations

Focus on areas of high compliance risk

Numerous available data-gathering techniques

Reports to management, investigations, and corrective steps

Violations by company’s provider-clients

Responding to Violations and Taking Corrective Action

Prompt, thorough investigation to assess gravity

Several forms of corrective action

Personal interviews and document reviews

Full record of investigation compiled

Report to government authorities

Discovering violations by provider-client

Identify and return overpayments

Questions ???

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