The Healthcare Billing Compliance Office is a central resource in promoting education and monitoring regulatory compliance for medical and dental documentation, coding and billing. The Office assists in identifying and eliminating potential risk areas by activities which includes but is not limited to; providing education and training on regulations from Federal, State and other regulatory agencies affecting professional billing; conducting compliance validation reviews; recommending any needed changes or additions to billing policies and procedures; researching inquiries concerning proper billing practices; review, investigate and respond to reports of potential non-compliance; and recommending remedial actions for non-compliance.
Coding and Billing Standards
Honesty and accuracy in billing for payment by a Federal Health Care Program, or payment by any third party payer, is vital. Each health care professional employed by the University is expected to monitor compliance with applicable billing rules. No University employee shall submit, authorize or sign a false claim for reimbursement in violation of applicable laws and regulations. Claims for the provision of services and/or supplies should be submitted only by the University department or college that generated the charges unless an alternative billing arrangement has been approved by the Director of Compliance and the Vice President for Health Affairs and Associate Provost – Health Sciences Center.
University employed health care professionals will refrain from any of the following practices and work to identify and correct instances in which mistakes have occurred in the following areas:
- Billing for items or services not rendered or not provided as billed;
- Submitting claims for equipment, medical supplies and services that are not reasonable and necessary;
- Double billing resulting in duplicate payment;
- Billing for non-covered services as if covered;
- Knowingly misusing provider identification numbers, resulting in improper billing;
- Unbundling (billing for each component of the service instead of billing or using an all-inclusive code);
- Failure to properly use coding modifiers;
- Falsely indicating that a particular health care professional attended a procedure;
- Clustering (billing all patients using a few middle levels of service codes, under the assumption that it will average out to the appropriate level of reimbursement);
- Failing to refund credit balances; and
- Upcoding the level of service provided.
Billing to Receive Denial
A University department or college may bill Medicare in order to receive a denial for services, but only if the denial is needed for reimbursement from a secondary payer. The Medicare claim submission should indicate that the claim is being submitted for the purpose of receiving a denial in order to bill a secondary insurance carrier.
Waiver of Co-payments and Deductibles
University-employed health care professionals will not waive co-payments or deductibles except to the extent consistent with applicable laws, regulations and guidance issued by the Office of Inspector General. Permissible waivers may include, but are not necessarily limited to, waiver based on indigence and contractual write-offs and discounts.
Billing and Coding Queries
Billing and coding staff shall be able to communicate with and receive communications from University-employed health care professionals at all times. Billing and coding staff will not submit claims for reimbursement until all coding questions have been satisfactorily answered and appropriate documentation has been submitted by the appropriate health care professional.
Claims for payment will be coded and billed based on the documentation contained in the patient’s medical record. University-employed health care professionals will appropriately document the services and supplies provided to, or the diagnosis and treatment of, each patient and will complete medical records in a timely manner. Medical record documentation must be completed, legible and authenticated.
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