What Medical Billing Federal Mandated Guidelines Clinics and Medicals Require to Follow?

Medical Billing Federal Mandated Guidelines That Medicals Should Follow

The medical industry must follow compliance regulations and standards, which apply not only to doctors and nurses but also to third-party billing companies. Although medical companies are not offering direct services to the patients, they are in hold of a lot of sensitive data or information which, if wrongly used, can lead to a huge cost to the company and create a lot of trouble. So, to avoid this, understanding what federal mandated requirements and guidelines apply to medical billing businesses will help in relieving the company of the potential consequences.

Coding and medical billing specialists deal with a huge volume of sensitive information regularly. As coding and medical billing specialist, you will be handling patient, medical and healthcare providers, and insurance information. It is mandatory to secure this sensitive information at all times. You will also be held responsible for the electronic or physical transfer of this sensitive medical information between the various interested parties. If you fail to perform these duties within the federal guidelines and state laws, you might welcome the unnecessary federal investigation.

The medical billing companies must understand the federal requirements and standard protocols that they need to implement by the rules and laws of state and federal healthcare. 

An overview of the guidelines, as well as, the compliance requirements as directed by HIPAA (health insurance portability accountability act), healthcare reform act 2010, and OIG (officer of the inspector general) follows. The guidelines given by these specialized entities comprise the rules related to security, privacy, and filing requirements that you need to be well-aware of as coding and medical billing specialist.

HIPAA Compliance-for confidentiality (Medical Billing)

Passed by Congress in 1996, HIPAA was signed as a law by President Clinton. The major goals set by HIPAA are high maintenance of medical information with increased accountability and security. To be more specific, HIPAA established rules for the health insurance companies and healthcare providers to maintain the privacy of the information of their patients. 

The HIPAA guidelines apply to the gathering, classifying and transferring any private information to and from the patients. For coding and medical billing, the major aim of HIPAA is to curb any sort of fraudulent activity that might happen before or during the medical claim process. Also, HIPAA serves to establish standards for ensuring the confidentiality of patient information and transferring sensitive patient information electronically.

Medical billing companies must incorporate HIPAA confidentiality rules in their operating procedures and policies to safeguard the interests of their organizations.

OIG Compliance

Operating through DHHS, OIG ensures that the entities covered under it are confined to the security and privacy laws established by HIPAA, as well as, any other related federal requirements or legislations. Related to the coding and medical billing industry, one of the major goals of OIG is the prevention of fraudulent activities among the covered entities. As far as medical billing and coding are concerned, you as a medical provider must be vigilant about any potential activity in your hospital/clinic that might lead to fraud or abuse.

Below are listed some of the common practices that are considered fraudulent by OIG- 

Common Fraudlent Parctices By OIG
  • Unbundling codes- Unbundling is a common practice that refers to submitting separate insurance claims for those activities which can ideally fit into a single bill. 
  • Up-coding– Up-coding is a common practice that refers to submitting of higher patient codes explaining the patient’s condition more than it is necessary. For instance, a healthcare provider might up-code some additional tests that were not even performed on the patient concerned just to secure extra money from the healthcare insurance provider.
  • Under-coding– Opposite of up-coding, under-coding refers to the practice of leaving out a few codes for healthcare services rendered to avoid extra investigation by the OIG.
  • False medical records– Falsifying the medical records is perhaps the most serious fraudulent activity that can be committed by a healthcare provider. In such a case, the medical practitioner will falsify the medical records, such as the patient’s treatment history, treatment description, or payment history, for self-gain. If found guilty of falsifying the medical records, the concerned parties will have to face charges by the OIG.

If the OIG is suspicious about the healthcare provider or an insurance company committing fraud on their medical claims, they might conduct an audit. 

Understanding the Healthcare Reform Act of 2010

The most significant aspect of the healthcare reform act 2010 is its contribution towards the overall expansion of the healthcare system, as well as, its rigorous attempts to cover most of the people under its medical insurance claim. These attempts will be able to meet the additional health demand of the people as more and more individuals will receive coverage. It aims to increase protection in the form of more healthcare access for the people.

As you deal with thousands of patients each year, you must follow guidelines set by these healthcare agencies to ensure proper conduct, privacy, efficiency, and fairness in the medical billing services.