Medical billing rules and regulations are designed to protect you and your patients. These regulations help prevent abuse within the medical field and ensure that you, as a provider, receive fair and timely payment. However, maintaining compliance with medical billing regulations can be challenging. Given their dynamic nature, regulations often change alongside technological advancements and societal shifts.
This guide provides an overview of medical billing compliance and guidelines to help you keep your organization in check.
Medical Billing Compliance Regulations
Medical billing regulations and guidelines ensure providers and administrators uphold ethical standards. These regulations encompass the following:
Why You Need To Stay in Compliance
Not complying with medical billing rules and regulations puts your practice at risk. You could open yourself to lawsuits, hefty fines, and even jail time. At the very least, you could end up with insurance denials and damage your reputation within the medical community.
As regulations continually shift and evolve, you may unintentionally fall out of compliance, so regularly updating your knowledge of billing regulations is crucial for maintaining your integrity.
Medical Billing Compliance Components
Be mindful of these factors within your practice to mitigate non-compliance risk. Set up a compliance program that includes each of the following items.
Coding
Make sure you are always accurate with medical coding. Keep your coding systems up to date, including:
- Current Procedural Terminology
- The International Classification of Diseases
- Healthcare Common Procedure Coding System
Stay updated on new coding rules and guidelines and make current codes easily accessible to your medical billing team.
Centralized Documentation
Keep tabs on the services you provide to ensure you can demonstrate compliance with accurate and detailed documentation. Each bill should correspond accurately to the medical records. Keeping your compliance documents in a central location enables easy access during audits and in the event of a claim denial.
Compliance Training
If you don’t have a compliance program, create one and incorporate regular training sessions. Ensure the participation of all personnel, including administrators and caregivers. Train your team on accurate coding practices and ensure everyone understands the billing process. Cover relevant laws and regulations applicable to your organization in these training sessions.
Regular Audits
Expect regular external audits that verify your compliance with existing regulations. These audits typically identify coding errors, missing documentation, and other discrepancies. It's crucial to have a plan in place to correct any mistakes uncovered during these audits.
Your organization can also perform internal audits overseen by your administrative team. Have your team focus on these critical areas:
- Ensuring the use of correct codes for services and supplies
- Verifying claims are accurate and complete
- Identifying any missing supporting documents and records
- Assessing time to bill
- Evaluating if claims adhere to local and federal regulations
- Reviewing follow-up procedures on claim denials
Steps You Can Take To Ensure Compliance
Implementing a medical billing compliance program can boost your organization's compliance efforts. You can also take the following steps to strengthen your compliance practices.
Respond to Claim Denials
Claim denials are a common occurrence, and following up on them quickly improves your chances of having the denials reversed. Agencies, including Medicare and Medicaid, have specific timeframes for responding to claims.
Making a habit of promptly responding to claim denials helps you get paid faster while staying in compliance. It also helps you identify common mistakes that may be contributing to denials.
Improve Your Onboarding Process
Turnover remains high in many industries, and healthcare is no exception. Due to high turnover rates, you may constantly rotate your administrative staff and medical billers, which can put your organization at risk for compliance issues. Rushing to fill vacant positions can result in hiring individuals who may lack the necessary compliance skills and expertise.
You can mitigate this risk by integrating compliance policies into your employee onboarding process. Clearly communicate your compliance protocols and ensure new employees attend compliance training as part of their new-hire checklist.
Stay Compliant by Outsourcing Your Medical Billing
PUREDI provides medical billing services delivered by a team with over two decades of experience in medical billing and practice management. We offer 100% cloud-based intelligent software and revenue management services.
Our technology helps automate parts of the billing process. It can flag claim errors before they are submitted so we can correct them and avoid a claim denial. We also stay on top of medical billing regulations to help your organization stay in compliance. Take advantage of our cutting-edge technology and consulting services and elevate your medical practice now.
Schedule a demo to learn more.
