Medical Billing Compliance Plans

Compliance Plan Strategies The need to correctly document medical records, apply appropriate billing codes, and accurately charge payers for medical procedures and services is essential for today’s medical facilities. Physicians rely on medical insurance specialists to process claims so that they can be reimbursed for their services. This essay will emphasize the importance of correctly submitting claims for reimbursement, as well as, how compliance plans are put in place to benefit everyone involved in the billing and coding process. Steps to an effective compliance plan are as follows: 1. Accurate and complete medical record documentation 2. Appropriate code use for diagnoses, examinations, and HPI 3. Linking the correct procedural code with the correct diagnoses code 4. Correctly using modifiers The following OIG guidelines are also an important part of an effective medical record compliance plan: 1. Records should be clear, concise, clear, and legible 2. Past and present diagnoses should be clearly present in the medical record. 3. Risk factors should be identified 4. If ancillary or diagnostic ordering services are not documented, the rationale should be inferred by an independent reviewer 5. A patient’s progress, response or changes to treatment, or any revision in the diagnoses should be documented 6. Each patient encounter should be documented, along with the reason for the encounter. 7. Diagnostic test results, clinical impressions, plan of care, and date of service should also be documented The potential risk for improper billing includes fraud investigations, loss of revenue, disciplinary actions, exclusions of government-based

References: Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.). Boston, MA: McGraw-Hill. Sosa Re, Cascardo. National Medical Association, 2002.