Evaluating Compliance Strategies

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Evaluating Compliance Strategies
June 4, 2013

The compliance process is critical when it pertains to the billing and coding process. It is imperative for Medical Insurance Specialist to remain current on the patient’s participation in contract as well as the medical insurance policies, so there will not be any billing errors. Maintaining a communication with the payer will also prevent billing errors. Such regulations and laws are in place for to protect the patient’s financial state, prevent errors of billing and coding, and to link procedures and diagnoses correctly. Becoming knowledgeable of the billing rules should also help prevent billing errors as well. In this assignment, I will discuss how important it is for medical staff to be knowledgeable of the billing and coding compliance strategies. The first strategy to compliance is to carefully define bundled codes and know global periods. This is important, medical insurance specialist must be knowledgeable of what global periods are for surgical procedures and what specific procedure is included in the bundled codes. The second strategy is to benchmark the practice’s E/M codes with national averages. This strategy helps when conducting comparisons with the national averages, because it helps to monitor upcoding. The third strategy is the use of appropriate modifiers. This strategy helps prevent double billing or unbundling. Modifiers such as -25, -59, and -91 are most important when billing in compliance. The fourth strategy is becoming clear on professional courtesy and discounts to uninsured/low income patients. Unfortunately, providers can no longer provide professional courtesy to patients per OIG’s Compliance Program Guidance for Individual and Small Group Physician Practices. However, if the patient may qualify for discounts if they are either uninsured or has low income. According to textbook Medical Insurance: An Integrated Claims Process Approach, “The practice’s method for selecting people...
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