Staying Compliant with Medical Billing Regulations: Key Considerations for Your Practice

medical billing regulations July 14, 2023

For your practice to remain financially stable, you must ensure that your medical billing is accurate. Medical billing compliance, however, has always been a complex and ever-changing area of health care.

Your practice may suffer adverse consequences if you don’t comply with medical billing regulations, including reimbursement denials, fines, penalties, and in severe cases, even legal action. That is why you should stay on top of all federal, state, and private insurance laws and guidelines since their rules constantly change.

This blog will discuss the importance of adhering to medical billing regulations and how to improve your practice’s billing compliance.

Why Is Medical Billing Compliance Important?

Non-compliance in healthcare carries significant consequences, including potential legal actions. The severity of these consequences stems from the risks posed to patient safety and privacy.

If your practice fails to comply with regulations, you may face financial penalties, legal charges, and damage to your reputation. Patients value high-quality care and are more likely to choose healthcare providers with no history of lawsuits or complaints.

That is why it is essential to implement a healthcare compliance program for several reasons:

✅ The purpose of medical billing compliance aims to prevent fraudulent or abusive practices toward patients;

✅ Medical practice compliance and regulations safeguard patient privacy and safety while encouraging providers to deliver high-quality care to all patients;

✅ Compliance program regulations not only shield patients but also safeguard valuable information; and

✅ These regulations also outline the proper procedures for billing patients accurately. 

Compliance with medical billing and coding regulations decreases the likelihood of cyberattacks and data breaches. Moreover, complying with federal laws and regulations protects your patients and establishes yourself and your practice as a reputable healthcare provider.

5 Medical Billing Best Practices to Ensure Compliance

Applying these best practices is vital to smooth medical billing and reimbursement flow.

Here are five best practices to ensure compliance in your practice:

1. Monitor and Track Compliance

Keeping track of compliance is crucial to maintaining a well-functioning practice. When compliance issues spiral out of control, realigning your practice’s routine with the required standards becomes challenging. 

Fortunately, technology tools are available to help you regain confidence in compliance efforts and ensure adherence to essential benchmarks, including billing systems, provider credentialing software, medical coding platforms, and payer contract review solutions.

As a healthcare provider, you know that medical billing regulations can be complex and ever-changing. Staying updated and knowledgeable about potential compliance concerns is the only way to stay ahead. 

Maintaining a proactive and vigilant approach is the key to preventing the escalation of compliance issues. By embracing modern technological solutions, you can effectively mitigate risks and ensure that your practice operates within the boundaries of regulatory guidelines.

2. Streamline Clinical Workflows

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established national standards to safeguard sensitive protected health information (PHI) against unauthorized disclosure. Since PHI includes health records and information associated with a person’s identity, HIPAA guidelines help ensure your practice’s compliance with the Privacy Act.

Moreover, PHI includes lab forms, insurance statements, collection notices, and prescription forms, which could pose compliance risks. By streamlining your clinical workflows, you can ensure that only authorized individuals can access specific information.

Outmoded communication methods, such as paper-based systems or unsecured email, pose significant risks to sensitive information. In the past, hospitals and physician offices relied on those technologies, which delayed patient transports and consultations.

By adopting modern and secure communication technologies, you can effectively protect data privacy and maintain compliance. The HIPAA Journal recommends secure texting over old-fashioned communication channels like pagers, fax machines, voicemail, and email. Because most people always have their cell phones with them, HIPAA-compliant messaging is easier, faster, and more convenient than paging, faxing, emailing, and voicemail.

3. Audit Your Internal Processes

You should consider hiring a third-party auditor to review your medical billing and coding procedures in performing internal audits. These audits help identify areas that pose a high risk, workflow inefficiencies, and potential improvements. However, your medical practice must create its internal auditing strategy to maintain compliance. An internal audit identifies inefficiencies and opportunities before a third-party audit arrives. As part of this process, you also ensure that your compliance practices meet legal requirements.

4. Establish Procedures, Policies, and Schedules

Having well-defined policies, procedures, and schedules in your handbook helps maintain medical billing practice compliance. The Office of Inspector General (OIG) recommends that healthcare boards establish a comprehensive policy that outlines quality improvement goals and patient safety programs. Moreover, this policy ensures that all stakeholders share a unified vision for quality within the organization. Integrating these objectives into employee performance evaluations and incentive compensation can further enhance compliance efforts. 

5. Identify and Assess Risks

As a healthcare provider, you must mitigate cybersecurity risks to comply with regulations. At any given time, malicious hacking or unauthorized access can occur, often without warning. Vulnerabilities can be as simple as an employee using an unsecured mobile phone connected to your practice’s network. That is why external consultants can also assist you in assessing your practice for these hidden compliance risks, offering valuable insights and advice.

Laws Regulating Healthcare Compliance

Several vital laws regulate the healthcare industry to protect patients and ensure fair access to healthcare. Here are a few of them:

  1. Health Insurance Portability and Accountability Act (HIPAA): This law prevents sharing of private patient information without the patient’s consent or knowledge.
  2. Health Information Technology for Economic and Clinical Health (HITECH) Act: HITECH expands HIPAA and sets standards for using information technology in implementing electronic health records (EHR) in healthcare facilities.
  3. Emergency Medical Treatment & Labor Act (EMTALA): This law ensures that everyone can receive emergency medical treatment regardless of their ability to pay.
  4. Patient Safety and Quality Improvement Act (PSQIA): This law encourages reporting and resolution of patient safety issues and establishes a database of Patient Safety Organizations (PSOs).

Tap Into Our Expertise

Regulatory and compliance requirements are highly complex in medical practices. The good thing is you have everything to gain by attempting and investing in these medical billing practices. Suppose you are looking for medical billing professionals.; in that case, we can assist you in denials of reimbursement, billing and compliance issues, and disputes with providers and payers. Errors and misunderstandings can be stressful, as we all know.

At 5 Star Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional pain management billing service.

Schedule a call with our experts today!

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