Evaluating Compliance Strategies

To be able to receive the maximum reimbursement for health care claims, there is a compliance process. To ensure correct coding and billing procedures where used, correct physician documentation must be used to support the medical claim, this includes using correct codes and procedures aid in the prevention of fraudulent claims. By using correct codes, it ensures that the compliance process was completed with the up most integrity and honesty. Incorrect or fraudulent coding can and often times does cause a ripple effect that can have a major impact on the coding specialist, the physician or facility and even the patient. The claim form often has to be resent, recoded, and resubmitted which delays the payment on the claim. This could put a temporary or permanent hold on a procedure the patient requires. A biller/coder who makes these mistakes often can be seen as a liability and be at risk for losing his/her job and reputation as a specialist in this field. Following compliance procedures also helps set the price that a patient may be required to pay. If there are multiple errors in the claims process, a patient’s out of pocket costs may be higher than expected because their insurance will have denied benefits. Often the mistakes are seen as just that, a mistake. Accidentally entering one wrong letter or number is seen as a mistake, but knowingly charging for service that you know were not completed, is fraud and it is illegal. By following all the steps of compliance, we can ensure that providers, payers, and patients get billed and reimbursed in a timely manner and correctly. Think of it this way, would you want to be denied or overcharged for a service that you know was covered, or would you want to be charged for a service that you never received. I know I wouldn’t.

The Medicare National Correct Coding Initiative (CCI) controls coding that is considered improper or that can or does lead to an inappropriate payment of Medicare claims. There are four components...