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

Tips for Accurate Medical Billing in Small Healthcare Practices in 2023 June 2, 2023

Medical billing plays an increasingly important role in the financial success of small practices. As a healthcare provider, accuracy in this aspect is essential. With ICD-11 and billing updates of 2023, medical practices must stay on top of medical billing best practices to maximize revenue and minimize billing errors. 

This blog post will highlight five valuable tips for ensuring accurate medical billing and coding in small healthcare practices.

5 Best Tips for Accurate Medical Billing in Small Healthcare Practices

These are tips for improving small medical practices’ bottom lines through medical billing best practices.

1. Streamline Medical Billing Processes

Technology can be a crucial component in streamlining the billing process. With technology, patients can pay in multiple ways via seamless digital transactions at their simplest level.

Modern technology, such as medical billing software for small practices, allows doctors, staff, and administrators to share information more smoothly. Additionally, some medical software systems can assist in automating steps in the billing process. For instance, you can use these systems to obtain medical codes and to ensure that your medical claims comply with insurance reimbursement guidelines. 

The good thing is these software bots are provided with basic data entry procedures to ensure that the required data is captured from Electronic Medical Records (EMRs) and added to the billing system correctly. By doing so, you will save staff time and avoid unexpected denials.

2. Ensure Accurate Patient Information

Knowing your patients’ basic information when filing medical claims is equally important. Even the slightest mistake can result in rejecting or denying your claim. To ensure accurate and clean patient information on all your claims, follow these steps:

Collect patient information: Gather the details like the patient’s age, gender, address, and phone number. If it’s necessary to send a bill to a collection agency later, ask a patient for photo identification at the first appointment.

The best medical billing and coding tip — verify the patient’s insurance coverage and eligibility. As a provider, you must perform this process before giving any services. At the time of service, clarifying the patient’s financial responsibility is essential. Also, obtaining accurate insurance information in advance will help prevent claim rejections and save time. Don’t forget to ask about copays and remind the patient of them.

Nowadays, most practices use advanced medical billing and coding software. Patients only have to provide their information once with this software and don’t have to do it every time they go to the hospital or clinic.

3. Practice Proper Coding

Current Procedural Terminology (ICD) and International Classification of Diseases (ICD) codes change frequently. That is why staying updated on these code changes is crucial to ensuring accurate billing. 

A lot depends on accurate coding and conformity to regulations regarding medical billing. Healthcare, as a highly regulated sector, does not exempt small practices from adhering to rules. These regulations address the medical billing and coding of healthcare and physician services from various sources.

• Health Insurance Portability and Accountability Act (HIPAA)
• Medicare and Medicaid guidelines
• Certain health insurance companies may require specific billing and coding requirements.

Furthermore, adhering to the coding standards established by regulators and payers makes healthcare data more accurate and consistent, facilitating effective communication among healthcare providers. Thus, maintain record-keeping of coding changes to prevent claim denials and underpayments. 

On the other hand, upcoding and unbundling are also serious concerns in medical practices. Training and regular audits are therefore essential. You can prevent unintentional or intentional errors by training your staff on proper coding guidelines and the importance of ethical billing practices. You must also conduct regular internal audits to avoid coding discrepancies, ensure compliance with the law, and maintain its integrity.

Remember: Upcoding and billing issues can damage your healthcare business irreparably, so take these preventative measures to safeguard it.

4. Manage Claims Effectively

According to Kaiser Family Foundation analysis, some Healthcare.gov marketplace payers claim denials rates as high as 80%. If this continues, insurers could lose millions in revenue.

Meanwhile, inefficient claims management processes increase the cost of processing claims, impacting the bottom line. Several factors contribute to this problem, but these are the most common:

The act of duplicating billing: Failure to confirm that a service has been reported or reimbursed.

Lack of documentation: There were incorrect, illegible, or incomplete records of the procedure or visit, making verifying and completing the claim difficult. Thus, the biller should follow up with the provider in these cases.

Explanation of Benefits (EOB) not attached to a denied claim: Insurers that still require physical claims might fail to attach the EOB to a denied claim, making it more challenging to identify and fix the error.

Denial codes or claim number references were missing or unclear on a denied claim: Most insurers accept electronic or online appeals. In these cases, no EOB is provided; instead, claim numbers and denial codes are provided to explain the reason for the denial. However, a missing or unclear code can make locating and correcting the problem more difficult.

So, what are the medical billing best practices for these issues?

If any information on claims needs to be more consistent, complete, or clear, double-check the claims before submitting them. Make sure to follow up with the insurance company for any errors they encounter after submitting the claim.

You must resubmit a denied claim with the attached EOB to avoid errors such as those listed above. Sometimes, an insurance company will return a claim without an EOB or denial code. 

This situation makes it challenging to identify and correct errors. You can contact a company representative to find out which portions of the claim were problematic or if you can send an EOB.

5. Outsource Your Medical Billing Process

One of the most effective medical billing and coding tip is outsourcing. 

According to a recent publication, outsourcing allows you to focus on other aspects of your business while providing customers with high-quality services. It’s similar in healthcare organizations. Outsourcing medical billing and coding is a cost-effective way to eliminate in-house staffing. 

For small practices, hiring a company that offers all aspects of medical billing services is beneficial. The right company can assist you with insurance billing, coding, and collection efforts. Ensure they have advanced technology, like medical coding software, which can simplify your billing process.

Tap Into Our Expertise

This 2023, learning some medical billing best practices will help you ensure financial stability and compliance. While there are many ways to streamline medical billing, the best way still depends on your practice’s particular needs. 

At 5 Star Billing Billing Services Inc, we offer high-quality medical billing services for small practices! Our goal is ALWAYS to meet your medical billing and coding needs, saving your staff time and resources. 

Want to learn more about the benefits of outsourcing your medical billing? You can also get more medical coding and billing tips from us by scheduling a call with our experts today!