Medical billing is the procedure for generating insurance claims for healthcare treatments given by clinicians and provider organizations to receive payment. After turning a healthcare service into a billing claim, the medical biller keeps track of the claim to ensure the organization gets paid for the provider’s work.
The term “medical billing compliance” refers to taking precautions inside a healthcare organization to eliminate the possibility of fraud, waste, or abuse. A compliance strategy is a dynamic, continuous procedure that guarantees that all medical organizations adhere to the highest legal, ethical, and moral guidelines.
Compliance fosters an environment in a healthcare organization where people try to stop, find, and fix things that could lead to theft, waste, or ill-treatment. To function efficiently, every healthcare firm must maintain corporate compliance.
Compliance ensures everyone follows the proper procedures and knows the expectations to keep operations running correctly. But the healthcare sector’s compliance stakes are significantly higher than in other sectors. If a nurse or physician fails to execute the correct procedure, they may injure a patient or another staff member.
Medical Billing Legal Requirements
Medical billing compliance aims to prevent the submission of incorrect healthcare claims to insurance companies (federal, state, and commercial). The main objective is to stop corruption, waste, and mistreatment.
Here is a summary of some laws and acts concerning healthcare compliance.
1. HIPAA (Privacy and Protection): The HHS Secretary was obligated by HIPAA, also known as the Health Insurance Portability and Accountability Act, to create regulations preserving the safety and confidentiality of specific health records.
HHS released the HIPAA Privacy Rule and the HIPAA Security Rule to comply with this mandate. The Privacy Rule, or Rules for Privacy of Personally Identified Health Information, sets national guidelines for protecting certain health information.
2. The Affordable Care Act and Medical Billing: The ACA intends to streamline medical billing procedures and increase patient transparency. One of the essential parts of the Affordable Care Act is the Health Insurance Marketplace. This is where people and small businesses can compare and buy health insurance plans.
The purpose of the Marketplace was to simplify the process of finding and selecting a suitable health insurance policy for individuals.
3. Stark Law and Anti-Kickback Statute: It is illegal under the AKS to knowingly and deliberately offer, pay, solicit, or receive compensation to encourage or promote patient referrals. Primarily to generate business for any product or service covered by a government healthcare plan. It is crucial for healthcare facilities to check the AKS for any recent revisions.
A common name for the Stark Law is the Physician Self-Referral Law. Providers cannot recommend patients for “specified health services” covered by either Medicare or Medicaid under the terms of this act. Most of the time, these conflicts of interest come from organizations with which the doctor or a member of the doctor’s family has financial ties.
4. False Claims Act: Providers of medical services who seek payment from federal healthcare programs like Medicare and Medicaid are subject to the provisions of the FCA. The legislation forbids filing incorrect or fraudulent claims to these programs and making false assertions supporting claims.
Compliance programs discover and resolve billing issues, teach staff about fraudulent activity and abuse legislation, and monitor and audit billing processes.
Medical Billing Common Legal Issues
These unethical medical billing practices, whether deliberate or not, have plagued the system and significantly complicated the lives of patients and the duties of medical professionals. Unethical billing practices have adversely impacted the medical industry. Because of this, the patient’s life and the medical provider’s employment are at risk.
Errors are inevitable in every sector, and a few dishonest professionals will attempt to exploit the system. These strategies are likely to affect both patients and medical professionals. For example, a patient may have to pay for an expensive medical service, while a doctor or nurse may be charged with a crime and sent to jail. The following section describes the prevalent legal difficulties in medical billing.
1. Insurance fraud
When fraudulent or deceptive data is submitted to a health insurance company, this practice is called health insurance fraud. The goal is to charge the policyholder, another party, or the organization providing services for illegitimate benefits. An insured person or a health service provider both have the potential to commit the violation.
A subscriber alone may defraud their health insurance by:
➢Giving another person permission to use their name and insurance to get medical care.
➢Paying for medications with health insurance that a doctor did not prescribe.
Medical professionals may engage in fraud by:
➢Invoicing for unperformed services, processes, or materials.
➢misrepresenting a patient’s diagnosis to support examinations, surgeries, or other treatments.
➢providing useless services to profit financially.
2. Upcoding
Upcoding refers to sending Medicare or other payors an invoice for a costlier service than the one rendered.
Examples comprise:
- The duration it took to complete the treatment was exaggerated. Misrepresent the tools needed for the process.
- To misrepresent the personnel that assisted in the procedure.
3. Unbundling
Unbundling is the fraudulent practice of sending separate bills for a group of procedures that should be billed under a single, all-inclusive code. For example, a doctor might order blood tests for a specific patient. In this scenario, a laboratory may engage in fraudulent activities by invoicing for each test it performs to increase its revenue.
4. Balance
BillingBalance billing, sometimes known as surprise billing, is when a medical professional (a doctor, for instance) bills a patient after the patient’s health insurance provider has paid their portion.
For instance, if the company charges $100 but only receives $70 in payment, they may still charge you $30. Your preferred provider can only charge you out of pocket for covered services.
5. Violation of Privacy and Confidentiality Laws
Regarding medical care and billing, privacy and secrecy are very important. Medical billing violations of confidentiality and privacy regulations can have significant implications for individuals and medical providers.
Some cases of medical billing that breaches confidentiality and privacy regulations include:
➢Providing unauthorized parties with patient medical details.
➢Giving out health details about patients without their permission.
➢Keeping patients’ medical records vulnerable to theft or misuse.
Legal Compliance in Medical Billing
A corporate compliance program is essential for the success of any healthcare firm. Compliance assures that operations function smoothly by verifying that everyone adheres to the correct procedures and knows the standards. Compliance procedures that meet well-planned criteria and explain the rules a business will follow show auditors that a provider is submitting claims in good faith. In addition, if claims are submitted accurately from the beginning, it will help promote a better cash flow.
Medical Billing Compliance Measures
Medical practice directors strive to run their businesses as smoothly and effectively as possible, but it often feels impossible with so many demands on their time. The fundamental goal of healthcare compliance is to guarantee that patients receive the highest possible quality of care while reducing expenses. When a practice is appropriately optimized, all aspects, from patient care to compliance requirements, are efficiently controlled.
The following measures are essential for ensuring compliance in medical billing:
- Establish a moral standard
- Outline the staff’s plan for continuous training
- Determine the appropriate actions to fix the non-compliance
- Describe the auditing and continuing evaluation procedure
- Reinforce the significance of establishing a culture of compliance
Medical Billing: Legal Implications of Non-compliance
There are profound implications for not complying with medical billing regulations. Examples include the potential for financial losses, security breaches, license suspensions, company interruptions, poor patient treatment, a decline in credibility, and reputational damage.
Punishment for Crimes
Providers participating in deceptive or abusive billing methods may also risk criminal prosecution. Depending on the seriousness of the offense, criminal consequences may also include penalties and imprisonment.
Dispute resolution and litigation
Non-compliance in the healthcare industry exposes your company to lawsuits, fines, and penalties. They have a significant effect on the legal costs of your company. But you can lower the price of settlements if you show that you put security measures in place and that your staff was instructed and aware of these protections.
Clinical Implications
A patient’s treatment efficiency can suffer due to the ripple influence of non-compliance. There will undoubtedly be more problems with patient care if you refrain from using ineffective techniques and procedures. If your hospital fails to meet norms and standards, the patients you vow to treat will suffer.
Non-participation in federal programs
The ability of providers to participate in federal healthcare programs like Medicare and Medicaid may be suspended if they use dishonest or abusive billing techniques. The length of this ban ranges from 5–10 years, according to the nature of the crime.
Organizational Sanctions
Medical professionals who indulge in dishonest or abusive invoicing methods risk losing their licenses or having their privileges suspended.
Conclusion
A thorough examination is necessary for a stable and thriving medical practice. By following and adhering to healthcare legal compliance, policies, guidelines, and internal audits, there will be less chance of fraud in medical billing.