The Healthcare Billing Compliance Office is a central resource in promoting education and monitoring regulatory compliance for medical and dental documentation, coding and billing. The Office assists in identifying and eliminating potential risk areas by activities which includes but is not limited to; providing education and training on regulations from Federal, State and other regulatory agencies affecting professional billing; conducting compliance validation reviews; recommending any needed changes or additions to billing policies and procedures; researching inquiries concerning proper billing practices; review, investigate and respond to reports of potential non-compliance; and recommending remedial actions for non-compliance.
Coding and Billing Standards
Honesty and accuracy in billing for payment by a Federal Health Care Program, or payment by any third party payer, is vital. Each health care professional employed by the University is expected to monitor compliance with applicable billing rules. No University employee shall submit, authorize or sign a false claim for reimbursement in violation of applicable laws and regulations. Claims for the provision of services and/or supplies should be submitted only by the University department or college that generated the charges unless an alternative billing arrangement has been approved by the Director of Compliance and the Vice President for Health Affairs and Associate Provost – Health Sciences Center.
University employed health care professionals will refrain from any of the following practices and work to identify and correct instances in which mistakes have occurred in the following areas:
- Billing for items or services not rendered or not provided as billed;
- Submitting claims for equipment, medical supplies and services that are not reasonable and necessary;
- Double billing resulting in duplicate payment;
- Billing for non-covered services as if covered;
- Knowingly misusing provider identification numbers, resulting in improper billing;
- Unbundling (billing for each component of the service instead of billing or using an all-inclusive code);
- Failure to properly use coding modifiers;
- Falsely indicating that a particular health care professional attended a procedure;
- Clustering (billing all patients using a few middle levels of service codes, under the assumption that it will average out to the appropriate level of reimbursement);
- Failing to refund credit balances; and
- Upcoding the level of service provided.