How not to Wear an Orange Jump Suit: Medical Billing and Coding Compliance Issues

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One of the most important things any medical biller or coder should be aware of is regulations regarding the industry. Laws that govern the healthcare industry can come from the federal, state or local level. In addition to legal issues, billers and coders must also deal with rules imposed by payers, accreditation agencies and their own employer. The volume of regulations can make anyone’s head spin, but it is important to follow all laws. After all, no one really looks good in an orange jump suit!

Although it is unlikely someone in a billing or coding career would ever be arrested due to actions on the job, failure to follow rules and regulations can result in financial loss for the company and in loss of your job. Here are some tips to ensuring compliance at all times in your medical billing or coding career.

Know the Big Rules

No one can remember all compliance rules in a medical job, but everyone should commit a few of the biggest to memory. The most important rules in each organization should be provided during orientation or training, but here are a few that are universal to healthcare.

  • Health information is private. You cannot share any information that could identify a patient with any other entity without the express written permission of the patient. This means that if your adult cousin is a patient and you bill her claim, you cannot discuss the information with your aunt. In fact, you should probably not even discuss the information with your cousin, as you are not her healthcare provider.
  • Health information is need-to-know. You should not discuss information within your organization unless there is a productive reason for the exchange.
  • Passwords are unique to you. You should never share log on information for any program you use at work, and should not write passwords down.
  • Claims should accurately reflect services rendered. Falsifying claims to increase the amount of collections is a federal offense.
  • The portion of any charge that is the patient’s responsibility usually cannot be waived without an attempt at collection or documentation of indigence.
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Use Available Resources

If you are working for a large company or hospital, you likely have access to legal, compliance and knowledge management departments. Most of these departments have open door policies, help lines, email addresses and anonymous communication lines. Any time you are in doubt regarding the compliance of an action, you should check with these resources. You should not break chain of command, however. When searching for an answer to any medical billing or coding question, there is a process to follow. You should:

  1. Check your training materials and notes;
  2. Check with your supervisor or trainer;
  3. Check with your manager;
  4. Check with a compliance contact that can elevate the question if no one can provide an answer.

Take Accountability for Your Work

You should never complete any task that you believe to be against the law. If your supervisor or manager has directed you to complete such a task, you should ask to speak to them in private. Calmly provide them with an explanation regarding why you think the task is illegal or questionable. Sometimes, you may be misunderstanding the work, and they can offer guidance. If they cannot provide a satisfactory explanation on how the work does not break any rules or regulations and they insist you complete the task anyway, you should contact the compliance helpline for assistance. Most companies have a no-retaliation policy to protect employees who bring up compliance concerns of this nature. However, in very rare circumstances, you may have to make a choice between keeping your job and abiding by your ethics. In these cases, it is usually better to seek employment in another facility that will not ask you to break rules.

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