(Third-Party Billing Company Compliance in 2014 continued) a potential breach of the private payor’s contract, a provider’s actions in this regard could conceivably also represent a violation of federal or state law, depending on the facts. COMPLIANCE TIP #7: Do not limit your training to only your staff. Provide periodic provider training opportunities as well. effective compliance training is an important tool that must be implemented within the billing organization. However, this training should not be limited only to billing staff. It is important that compliance training also occurs at the provider level. Billing companies must look at the big compliance picture: a provider with effective compliance practices may mean higher rates of reimbursement and, therefore, more revenue for the billing company. Therefore, it is in everyone’s interests for third-party billing companies to work with their providers and assist them in remaining up to date on current documentation, coding, and billing requirements. From a practical standpoint, if your provider has not received proper training on documentation, coding, and billing, how can a biller reliably process a provider’s claims? COMPLIANCE TIP #8: Amend your contract to permit the periodic auditing of provider claims. eventually, all participating providers will be required to have an effective compliance plan in place if they intend to remain a participating provider in the medicare program. until that time comes, third-party billing companies should take steps that allow them to gain a better sense of the claims that are being submitted. To that end, billing company contracts should include a provision that allows them to periodically request that supporting documentation associated with a group of claims be submitted to them. This will allow billing companies to get a better idea of the quality of the provider’s documentation. It will also serve as a mechanism to audit the provider’s billing practices. COMPLIANCE TIP #9: Strengthen your complaint reporting systems. a third-party billing company’s complaint reporting system must be viable and strong in order to ensure that all compliance measures are being effectively executed. Thus, you must take steps to ensure that the lines of communication remain open with employees, patients, and other parties who may have concerns about your work or the provider’s billing practices. an example of an effective communication tool might include an anonymous e-mail address that can be used to submit complaints and concerns. If you operate a website, you may also 28 HBma BIllINg • maY. juNe.2014 want to establish a link where individuals can submit concerns. another option would be to establish an anonymous phone tip line. In essence, maintaining strong lines of communication can significantly enhance your compliance efforts. COMPLIANCE TIP #10: Help your providers better understand how their billing practices are viewed by the government. We believe it is imperative that every billing company knows how the billing practices of their providers compare to those of the provider’s peers. This is not a difficult task. It is relatively simple for most companies to conduct a utilization comparison of a provider’s evaluation and management claims and compare the provider’s billing practices with those of their peers. moreover, this is one of the most effective compliance tools that can be shared with a provider on an ongoing basis. using this information, a billing company can more accurately detect outlier claims and investigate more fully to ensure that the services billed actually qualify for coverage and payment. It is imperative that all third-party billing companies and their clients review their compliance practices to help ensure that all medicare program billings are appropriately handled. ultimately, every billing company, as well as medicare providers and suppliers, need to develop, implement, and adhere to an effective compliance plan. In doing so, you can ensure that your continuing obligation to fully comply with applicable statutory and regulatory requirements is being met. Robert W. Liles, Esq., is managing partner at Liles Parker, a health law firm with offices in Washington, DC; Baton Rouge, Louisiana; Houston, Texas; and McAllen, Texas. Mr. Liles represents physicians and other healthcare providers in administrative and civil proceedings around the country. He can be contacted at (202) 298-8750. His email address is rliles@lilesparker.com. Resources 1 “Compliance Program guidance for Third-Party medical Billing Companies,” 63 Fed. reg. 70138 (1998). 2 Ibid., 70149. 3 Ibid. 4 HHs-OIg, “updated special advisory Bulletin on the effect of exclusion from Participation in Federal Health Care Programs” (2013). 5 HHs-OIg, “Work Plan for Fiscal Year 2014” (2014).
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