Medical Billing & Coding as a Career
Claims assistant professional or claims manager, Coding Specialist, Collection Manager, Electronic Claims Processor, ... [Show More] Insurance Billing Specialist, Insurance Coordinator, Insurance Counselor, Medical Biller, Medical & Financial Records Manager, Billing & Coding Specialist
What are Medical Ethics?
Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's.
What does acting within ethical behavior boundaries mean?
carrying out one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding:
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Compliance regulations:
Most billing-related cases are based on HIPPA and False Claims Act
Health Insurance Portability & Accountability Act (HIPPA)
Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA?
Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA?
Insurance Reform-primary purpose is to provide continuous ins coverage for worker & their dependents when they change or lose jobs. Also Limits the use of preexisting conditions exclusions Prohibits discrimination from past or present poor health Guarantees certain employees/indv the right to purchase new health ins coverage after losing job Allows renewal of health ins cov regardless of an indv's health cond. that is covered under the particular policy.
What is Title II of HIPPA?
Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)?
Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers.
What is the National Correct Coding Initiative (NCCI)?
Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims.
How many edits does NCCI include?
2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI)
Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2)
Mutually Exclusive Edits (NCCI)
ID's code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing?
delayed processing & payment of claims reduced payments, denied claims fine and/or imprisonment exclusion from payer's programs, loss of dr's license to practice med
Who has the task of investigate and prosecuting health care fraud & abuse?
The Office of Inspector General (OIG)
Fraud
knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims?
State & federal agencies as well as private ins co's
What are common forms of fraud?
billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment
Abuse
incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse?
submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse?
Risk Management
Patient Confidentiality
All pt's have right to privacy & all info should remain privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule?
When using for TPO, Treatment (primarily for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Operations (for purposes such as training staff & quality improvement)
What is Employer Liability?
Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed w/in the context of their employment. Referred to as "vicarious liability. A.K.A "respondent superior"-"let the master answer". Means employee can be sued & brought to trial
What is Employee Liability?
"Errors & Omissions Insurance"-protection against loss of monies caused by failure through error or unintentional omission on the part of the indv or service submitting the claim. ***Some dr's contract w/ a billing service (clearinghouse) to handle claims submission, & some agreements contain a clause stating that the dr will hold the co harmless from "liability resulting from claims submitted by the service for any account", means dr is responsible for mistakes made by billing service, errors & omissions is not needed in the instance. *****However, if dr ever asks the ins biller to do the least bit questionable, such as write of pt's balances for certain pt's automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions.
What is a Medical Record & what is it comprised of?
documentation of the pt's social & medical history, family history, physical exam findings, progress notes, radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of clinical care and communication. [Show Less]
