Healthcare Compliance in Medical Billing

Healthcare Compliance in Medical Billing

Healthcare compliance in medical billing involves laws that come in fifty shades of grey. The U.S. Department of Justice (DOJ) and the U.S. Department of Health & Human Services (HHS) have joined and created HEAT, an organization to expose waste, fraud, and abuse concerning government insurance programs.Physicians Billing Service

Also, the Office of Inspector General (OIG) has a compliance program for individual and small group physician practices. While a date has not been yet set, the OIG requires certain compliance issues under the Affordable Care Act concerning billing and Medicare/Medicaid programs.

Once certified, medical billers, coders, and compliance professionals adopt a code of ethics. The compliance professional protects the practice or healthcare organization against fraud and abuse by training and educating staff members and personnel, implementing a compliance program, and sharing information. A policy for the facility should be worded so the employees can understand it, and it should not be lengthy or threatening. The compliance professional is a leader in the organization, and is often the practice manager or one of the physicians.

Solutions for Compliance in Medical Billing

The healthcare organization should have a reporting system to a federal or state agency when he or she feels that there is an issue with the practice. This person must also report to senior management or the board.

Physicians Billing ServiceThis is considered a “dual employment” arrangement, which exists between a private healthcare facility and the federal government. This relationship removes stress when it comes to enforcing rules, laws, and compliance, as well as when dealing with non-compliant individuals, groups, or boards.

A healthcare facility will be less likely to knowingly submit a false claim when the staff understands the compliance professional’s relationship and loyalty to the outside source, as well as the organization. This arrangement eliminates the need for whistleblowers, as the compliance professional is expected to function in this capacity.

To maintain compliance with set rules and regulations, the compliance professional communicates with insurance companies, physicians, and management regarding any compliance issues within the practice or facility.

Healthcare Fraud and Abuse

Patients and their medical insurance information are at risk for exploitation in numerous ways. This is considered fraud, and it increases costs and decreases confidence in the healthcare professional, facility, and system.

Medical billing fraud is a federal crime and consists of intentional deceit within an organization for profit. Healthcare abuse is where knowing intent to obtain some unlawful gain cannot be established, but the behavior to do so exists. Examples of this fraud and abuse include:

  • Using someone’s insurance information to get services or suppliescanstockphoto7430764
  • Phantom claims for supplies or services that were not provided
  • Unbundling services from a group for increased payment
  • Rendering medical care without an active license
  • Falsifying signatures or documents to support supplies and services
  • Duplicate claim submissions

Protect Yourself

A medical practice or healthcare organization should follow certain general guidelines to protect against preventable billing errors and improve quality of care given. Ways to protect yourself include:

  • Report any discrepancies to the health insurance payer or plan.
  • Ask the provider to explain the purpose for services and supplies.
  • Review the statement for accuracy after care is given.
  • Don’t sign blank insurance forms.
  • Safeguard patient’s insurance information.
  • Report instances were deductibles or co-pays are waived.


Federal Register, Oct. 5, 2000 (

Nash-Bloink, Jacqueline, “Design a Useable Compliance Policy for Physician Practices,” Health Care Compliance Association, April 2013 Conference (

SCCE, “Stress” Taking a Heavy Toll on Compliance and Ethics Professionals, Jan. 10, 2012 (

Clark, Ronald, “Asked Questions about the False Claims Act (‘FCA’) 31 U.S.C. 3729-33.

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