OIG Compliance

The OIG operating through the DHHS works to ensure that covered entities act within the confines of privacy and security laws established in HIPAA and related federal healthcare legislation. One of the OIG’s main duties relative to the medical billing and coding industry is the prevention of fraudulent activity among covered entities. As a medical billing and coding specialist you must be vigilant about potential activity that may be viewed as fraudulent by the OIG.

Some of the most common fraudulent practices that the OIG deals with include:

• Unbundling codes: Unbundling is a fraudulent practice of submitting separate claims to an insurance provider for services that could fit on a single bill. Providers send separate claims so that the various CPT/ICD-9 codes on each claim are “unbundled” from one another thereby maximizing their payment from insurance companies.
• Upcoding: Upcoding occurs when providers assign higher CPT/ICD-9 codes than necessary to explain a patient’s condition or services they received. For instance, a provider might upcode for extra tests that weren’t performed on a patient just to get more money from an insurance company.
• Undercoding: Undercoding is the opposite of upcoding, when a provider intentionally leaves out codes for healthcare services rendered. Providers may undercode in an attempt to avoid investigation by the OIG.
• Falsifying medical records: Falsifying medical records is perhaps the most egregious fraudulent activity committed by a healthcare provider. In this case, providers falsify a patient’s medical records, including histories of their conditions, descriptions of treatment, and payment histories for self gain. Providers and any staff guilty of falsifying medical records will be subject to prosecution by the OIG and other parties that may want to press charges.

If the OIG suspects that a provider or an insurance company is committing fraud on their claims, they may conduct an audit. The OIG has the authority as an acting party of the DHHS to enforce laws found to be broken by any covered entity. As a medical billing specialist it is in your utmost interest to adhere to the federal healthcare laws and regulations to avoid getting in trouble with the OIG. Check out the DHHS for more information about OIG compliance.

Understanding the Healthcare Reform Act of 2010

The most important aspect of the Healthcare Reform Act of 2010 for medical billing and coding purposes is its overall expansion of the healthcare system and its attempt to cover more Americans. These efforts to extend coverage will require many more people to become skilled medical billing and coding professionals simply to keep up with healthcare demands. Specifically, the law is estimated to enroll an additional 30 million Americans in various healthcare programs. As healthcare eligibility increases among the American populace, so too will the number of healthcare claims needed to be filed and processed. The most relevant effects of the bill are listed below.

Increased Protections for People Enrolled in Medicare

The Healthcare Reform Act is designed to increase healthcare access, including to those people who should already have access to care under current federal healthcare laws. The new law makes many preventive care services covered under Medicare at little to no cost to enrollees. Preventative services such as annual wellness visits and preventive screenings for conditions like cancer, diabetes, and HIV will now be covered for Medicare enrollees.

These increased protections and available services will help millions of Americans to receive necessary healthcare, but it will also result in many more claims per year to be filed with Medicare administrative contractors (MACs) across the country.

Mandatory Electronic Medical Records and Transactions

The most important component of the Healthcare Reform Act for medical billing specialists is the requirement that all providers use EHR systems by the end of 2015. This means that providers who deal with mostly paper claim forms will need to reorganize their billing department to handle electronic transactions. Those electronic transactions will need to meet the security and privacy standards required by HIPAA (like those established with the privacy and security rules) and other healthcare legislation.

The push towards EHR is also designed to minimize administrative burdens for medical billing coding specialists and other provider staff who deal with medical information. The Healthcare Reform Act of 2010 includes a number of suggestions for reducing this administrative burden aside from mandatory EHR, including the implementation of new recordkeeping software. These practices will ultimately make your job as a medical billing and coding specialist much easier and optimize the healthcare experience for all parties involved.

Healthcare administrative technologies change all the time, and providers can no longer delay learning how to work with them. The Healthcare Act of 2010 merely expedited the process of bringing all providers, insurance companies, and other covered entities into the healthcare digital age. There will be a huge demand for trained medical billing and coding specialists who can assist in this transition from paper claims filing to claims filed exclusively over digital networks.