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  • Writer's pictureRMK HOLDINGS INC.

How to Jump-Start a Billing Compliance Program

Updated: Sep 29, 2022

Yes, the future of the Affordable Care Act, which mandates all healthcare providers to have a billing compliance program in place, is uncertain. But, that does not mean that the U.S. government will not continue to put in measures to fight Medicare fraud by healthcare providers. Not with the U.S. saving over $1.5 billion in its effort to combat healthcare fraud and abuse, so far.

So, if you’ve been dragging your feet, in the hope that the Affordable Care Act will be repealed, it’s time to stop and put a compliance program in place. To get you started, here are some questions you should answer yes to, to start and implement an effective compliance program in your health facility.

Do You Have a Healthcare Billing Compliance Officer?

Having one individual man the position of a compliance officer is the way to go to ensure Medicare billing compliance is a priority for your facility. This designated compliance officer would be responsible for operating and monitoring the compliance program. S/he must also stay updated with Medicare rules and regulations, oversee the compliance committee, conduct audits, communicate results with staff members, and assess practice risks. The ideal compliance officer should be a high-level staff within the medical practice. S/he should also report directly to your healthcare facility’s top management, so they have accurate information about compliance risks and policies that may affect your organization and its practices.

Do You Audit Your Healthcare Billings Regularly?

There are three things conducting an internal audit can do for you. That is, reveal if you are obtaining sufficient initial information, detect if you are making improper billing and coding decisions, and determine if you are pursuing reasonable collection efforts.

Reviewing your claims regularly would help you catch discrepancies and resolve them before they become full-blown problems. The claim review should evaluate your entire claim submission process, including intake submission, eligibility, and preauthorization verifications.

Do You Carry Out an External Audit Annually?

Internal audits are not enough for an effective billing compliance program. Errors missed during internal audits can be caught by external audits, so they are vital. For external audits, you can get an external claim auditor with qualifications and experience in your specialty to run at least an annual check on your claims. Be sure to hire an external auditor with an appropriate credential such as Certified Coder or Certified Compliance Officer, for the job.

Do You Refund Overpayments Quickly?

As a healthcare provider, you are to refund Medicare overpayments within 60 days of discovering them. If this is not done, you become guilty of violations of the False Claims Act, which attracts a significant financial consequence. To avoid missing overpayments, put in place a process that starts with payment postings and involves regular reviews to catch any overpayments. Once overpayments are discovered, quickly refund them according to your Medicare Administrative Contractor’s refund process.

Do You Screen for Only Approved FHP Vendors and Staffing?

Individuals and entities excluded from the OIG database should not be associated with your services. If you employ them (even accidentally), you will incur a huge financial debt, as all payments paid to the individual or entity must be refunded as an overpayment.

So, to avoid dealing with vendors excluded from participating in Federal Healthcare Programs, check the OIG exclusion database monthly. If you’re already using an excluded vendor, you must take them off every activity associated with Federal Healthcare Programs immediately. Please speak to your legal counsel after you’ve discovered them.


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