09 Mar What are the reasons that health care providers contract with third-party billing companies to submit their claims for reimbursement
Please answer the following 4 questions and post in this Canvas Assignment for grading. 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
Introduction
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
8
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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