Outsourcing Can Help Maintain Compliance in Medical Practices

by Outsource Strategies International Medical Billing Company

With new government regulations, payer requirements, initiatives, and audits, maintaining compliance in medical practices and clinics comes with unique challenges. Compliance-focused activities relate to ensuring confidentiality of personal health information (PHI) and seeing that medical billing and claims submission processes are clean and compliant with federal regulations. A recent report in Investment News recommends outsourcing compliance functions as an ideal strategy for corporate CCOs. With the scrutiny and liability risks that medical practices face today, outsourcing compliance is a great option for them too. Outsourcing medical billing and coding to a reliable service provider will reduce risk of malpractice claims and insurance fraud and abuse, and prevent costly litigation.

Maintaining compliance is crucial for many reasons. The Centers for Medicare and Medicaid (CMS), is focusing more than ever on preventing fraudulent and abusive claims from being paid. Last year, ABC News reported that U.S. Government Accountability Office (GAO) estimated that, in 2015, about $60 billion dollars were lost to fraud, waste, abuse and improper payments. National and Local Coverage Determinations (NCDs and LCDs) are constantly being reviewed and revised. The National Correct Coding Initiative (NCCI) is changed to add and modify claim edits on a quarterly basis. Private payers frequently update their medical necessity standards and interpretations of codes, modifiers, and documentation requirements.

With advanced technology and adherence to industry best practices, professional medical billing companies are well-positioned to help physician practices stay compliant.

They have certified medical coders with in-depth and up-to-date knowledge of CPT codes, HCPCS Level II codes, HEDIS coding, and ICD-10 codes. By using the right codes and modifiers to report services, they will submit claims to meet payer standards and edits, maximizing reimbursement while effectively protecting physicians from charges of fraud and abuse.
Ongoing training and open communication are crucial for accurate billing. The staff in professional medical billing companies is trained in claim submission processes. They can potentially abusive billing patterns and recommend corrections to maximize compliance and legitimate reimbursement. Eliminating the chances of inaccurate claim submission will reduce the risk of audits and improper denials.
Specialty-specific medical coding and billing knowledge is another strength that expert outsourcing companies possess. This enables them to submit clean claims the first time, preventing problems such as denied claims, unpaid claims and claims flagged for audit.
In established health care outsourcing companies, the team is knowledgeable in compliance reviews, audits, and risk assessments. They will conduct mock audits to look for areas of weakness in physician practices. This is important for audit readiness and to stay liability-free.

Outsourcing to a HIPAA compliant medical billing company is necessary to protect sensitive patient information. This will ensure adherence to the privacy, security, and claim filing-related rules of the Health Insurance Portability and Accountability Act (HIPAA), the Office of the Inspector General (OIG), and the Healthcare Reform Act of 2010 follows.