Protect yourself with billing company’s compliance plan
Protect yourself with billing company’s compliance plan
With the dust settling on the Office of the Inspector General’s newest model compliance guidance, many physicians worry that the government has effectively turned third-party billers into a new class of government informer.
Ironically, however, now that the rules of the game have changed, your billing company’s compliance plan could be your greatest asset when it comes to fending off false claims allegations, experts say.
If a billing company doesn’t have a compliance program, then it’s harder to establish that it has effective safeguards against billing errors and outright fraud, says L. Stephan Vincze, president and CEO of Vincze & Frazer and a consultant to the Bethesda, MD-based International Billing Association. Ultimately, the physician practice group is responsible for the correct submission of bills. So if you don’t have a compliance plan and the billing company you work with doesn’t have one, then your potential exposure to liability under the False Claims Act increases dramatically.
"The standard in the False Claims Act is a reckless disregard,’" says Vincze, who helped draft the OIG’s compliance guidance for billers. "An astute prosecutor could effectively argue in any court that, with all the publicity surrounding compliance and all the associations making information available, not to have a program in place is a reckless disregard of trying to prevent fraud. If you employ a company without a compliance plan, then it can be presumed that you’re assuming the risk that the company may be out of compliance. And the way these things work, if a grenade goes off, shrapnel’s going to go everywhere and hit everybody."
If a third-party biller is meeting the requirements of the OIG’s plan, Vincze adds, you can at least be assured that the company is training its coders and auditing its own procedures to make sure it’s documenting properly. You and your staff don’t have to be the watchdog for its billing process.
To find out where you and your billing company stand, Vincze recommends reviewing your contract to find out whether it addresses any compliance responsibilities. In all likelihood, it doesn’t. If that’s the case, request a meeting with a billing company representative so you can amend the contract to spell out exactly who’s responsible for what. The idea is to eliminate the possibility of nasty surprises in case something goes wrong and federal investigators become involved.
In your negotiations with the billing company, insist at a minimum on the following points, Vincze recommends:
- The billing company will agree to include language in the contract stating that it will implement and maintain an effective health care billing compliance program that includes the seven elements for effective programs as outlined in the OIG compliance guidance.
- If the billing company does the coding, it must agree to provide specific annual training to its coders on improper coding practices, coding documentation requirements, confidentiality requirements, communication reporting requirements, and basic government and private payer reimbursement principles.
- The company will agree in the contract to maintain current coding and billing reference materials for its coders.
- It will agree to conduct regular periodic audits of credit balances.
- It will take all reasonable steps to ensure data integrity in computer systems.
Vincze also recommends including language in the contract that spells out the reporting structure if fraud is suspected.
Basically, if the billing company believes that the physician or practice group is knowingly submitting false documentation to get reimbursed, then under the guidance, it’s supposed to refrain from submitting the claim and notify the physician of its concerns. "The hope is that will be the end of the matter and it will be corrected," Vincze says. "This is a ticklish area, but my point is that the whole process should be included in the contract as something people know up front will happen."
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