(Third-Party Billing Company Compliance in 2014 continued) by both a provider and its third-party biller. a third-party biller’s compliance efforts can be rendered useless if their client does not have an effective compliance plan in place. unfortunately, most small physician practices are still behind in this regard. rather than ignore this systemic deficiency, we recommend that a billing company take some type of affirmative action to monitor the compliance efforts of the provider. even if a provider does have an active compliance plan, you will want to ascertain whether the provider is conducting periodic internal audits or reviews. If periodic audits are taking place, is the provider sharing its findings with you? are you, as the provider’s billing company, routinely working through claims that have been denied for payment by government and private payors? These questions are important in determining whether an effective compliance relationship exists between the provider and the third-party billing company. COMPLIANCE TIP #4: Conduct due diligence before bringing on a new client. It is important that the billing company accurately screens new 26 HBma BIllINg • maY. juNe.2014 clients before executing a contract with them. There are several steps that a third-party billing company can take to screen these potential clients. From the outset, the company should review the potential client’s specialty area. generally, the government views certain provider types as representing a higher degree of risk to the medicare Trust Fund than others. as a starting point, billers should consider how a specialty area is viewed in the enrollment and re-enrollment process. Is a provider type viewed as “limited,” “moderate,” or “high” risk by the Centers for medicare & medicaid services (Cms) when enrolling or re-enrolling in the medicare program? If so, there may be some precautionary steps that the billing company should take before engaging in claims processing for that provider. Third-party billing companies should also look to the provider’s history. They should determine whether the provider has ever been excluded from participating in the medicare or medicaid programs and also check out the provider’s licensure and disciplinary history. moreover, billing companies should find out if the provider has ever been investigated by the government or by a private payor special investigative unit. a review of the provider’s
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