Medical coding and billing professionals usually work behind the scenes, which means that in comparison with medical care providers, they do not get a lot of limelight. While many don’t mind, it is valuable to highlight how much they improve the efficiency of the healthcare system. The medical coding and billing practices that are currently in place streamline the care process experienced by both providers and patients.

A Brief History of Medical Coding as We Know It

Medical coding has its roots in 17th century England. Data about disease were collected and assigned numerical codes. These London Bills of Mortality were then used to assess the most recurrent causes of death. From their institution until the late 1830s, the bills’ greatest flaw was the lack of consistency in their terminology. At that time, British Epidemiologist Dr. William Farr instituted a uniform classification system. 

These improved bills served as the precursor to the International List of Causes of Death, which was fully realized by the 1930s. The list began to be used by the World Health Organization in its monitoring of international epidemiological phenomena, especially as the list further evolved into the International Classification of Diseases (ICD), which began in 1977 to collect disease and injury data beyond only that which resulted in death.

This change especially has expanded medical records and their usefulness exponentially, and a contemporaneous technological breakthrough made it possible. The commercially-available computer improved the efficiency of medical records and billing in a way that was desperately needed. Now search terms through databases are readily available, instead of spending valuable time searching through thick medical code books. This is not only more time-efficient, but also more cost-efficient, since new copies of such books do not need to be checked, updated, and reprinted each year to stay up to code.

The greater availability and specificity of diagnostic classifications provided by the current medical coding system allows medical personnel to provide more extensive and therefore better care. The current system, called ICD-11 since January of this year, has gone through many revisions to be as accessible and accurate as possible (hence the -11). Currently, there are over 140,000 ICD-11 codes.

How Do Medical Coding and Billing Meet?

Medical coders convert a patient’s medical experience into corresponding ICD-11 codes. They serve as translators so the billing process can be precise and does not get bogged down by medical terminology. Coders then send the codes to a medical biller, who is responsible for using the ICD-11 codes provided to create an appropriate bill. They first create a claim for the patient’s insurance company, which the latter then evaluates and returns. It is then up to the biller to determine how much the patient owes out of pocket.

This system of designating medical coding, billing, and insuring to different entities streamlines the record-keeping and financial aspects of healthcare. It allows medical professionals like doctors and nurses to concentrate on treating patients.

The Benefits of Outsourcing Medical Coding and Billing

More Dedicated Patient Care

When medical billing is outsourced to a designated firm, medical staff can focus on their patients, instead of feeling split between caregiving and administrative duties. Everyone at a healthcare facility benefits from this: patients can receive the dedicated care they need, and medical personnel can do what they do best.

Improve Customer Service

The other side of the coin also applies. If medical billing is performed by a third party and not a nurse that feels the need to race off to attend to patients, the people in administrative roles can give patients calling with non-medical questions a better experience. People calling to verify their coverage can have their questions answered in a more focused manner.

More Efficient and Compliant Claims Processing

Because all of the medical coding and billing is performed by someone dedicated to do them, outsourcing the processes saves a medical facility money and time. Everything is sure to be processed in the same way and in ways that are up to code.

Fewer Mistakes

Mistakes in the medical billing process have tremendous dividends. Sometimes they are not discovered immediately, which can cost a patient or practice thousands of dollars. The paperwork is also notoriously difficult to clean up, and the process can take years. Because designated medical coders and billers can do their work without dividing their attention between it and patient care, outsourcing medical billing yields fewer mistakes and is more efficient at protecting patient information. 

Boost Productivity

Without having to jump back and forth, separating caregiving and administrative work allows staff on both sides to be more productive. This can save a clinic or hospital a lot of money while providing better patient care. To outsource your medical coding and billing, reach out to Aspen Ridge Medical today.

With the financial systems of our medical institutions as nuanced as they are, taking precautions against healthcare fraud must be equally as nuanced. Fraud cases cost medical practices substantial expenses in investigations and loss of reputation and business. Accordingly, all medical practices should have established plans to avoid fraud and protect themselves and the patients they serve.

What is Healthcare Fraud?

Healthcare fraud is defined by HIPAA as deliberately and willfully implementing or attempting to affect schemes to abuse the health benefits of medical programs or acquire any of the financial assets using fraudulent claims, presentations, or promises. If someone seeks to utilize or circumnavigate established healthcare systems for their own personal gain, it is considered healthcare fraud.

Legal Provisions Against Fraud

There are three major laws that are specifically designed to limit fraud in healthcare settings. These serve as primary pillars of and corollaries to more general fraud legislation. 

Federal False Claims Act

The Federal False Claims Act is the United States government’s primary piece of legislation against fraud. First implemented during the Civil War, the act imposes civil responsibility on individuals who deliberately submit or initiate the submission of fraudulent claims to the federal government. Under the False Claims Act, whistleblowers are provided with job protection under the qui tam provision if they are filing against a party that has defrauded the federal government.

Anti-Kickback Statute

The Anti-Kickback Statute is designed to inhibit those who solicit compensation or give or accept remuneration for services provided by federal health programs. In other words, the statute brings legal action against those who incentivize referrals of federal healthcare programs. Intentional or complicit remuneration prohibited includes drugs and supplies and other non-cash incentives.

Physician Self-Referral Law

Also referred to as the Stark Law, the Physician Self-Referral Law forbids provider referral to receive services payable by Medicare or Medicaid at an entity in which the provider has a financial relationship. This may include services in which a physician or immediate family member has ownership, an investment interest, or a reimbursement arrangement. Providers who violate this law may face fines in addition to exclusion from participation in federal healthcare programs. According to its strict liability statute status, proof of specific intent to violate the law is not required to bring legal action against the party in question.

Recommendations for Providers

The Office of Inspector General (OIG) offers several suggestions to providers for protecting against healthcare fraud and responding in its event. Follow these to promote compliance within your organization and trust both among staff and clientele. 

A Designated Plan

A stringent plan of compliance is a strong defense against healthcare fraud. This plan should include policies which support a healthcare facility’s adherence to enforcement and which innumerate methods to combat suspected fraud, i.e. claims processing. Make sure that contingency measures and regulations are written clearly and policies are defined adequately. The plan of compliance should be distributed effectively among the staff and trained upon regularly. 

Chain of Command

Have designated individuals to whom employees may go to report suspicious activity. A Chief Compliance Officer at minimum is a necessity, and other personnel responsible for monitoring organization and compliance should be available resources to ensure efficient communication and above-board procedures and transactions. These individuals should report to the governing body of the clinic or hospital.

Detailed Reporting Strategies

Procedures for medical fraud reporting should be well-maintained and documented. They should also be easily accessible to staff; consider the use of a hotline. Make anonymity protection measures a priority to foster immediacy and candidness when fraud is reported. 

Defined Response Procedures

Have an established framework in the event of health fraud and abuse charges. Make all employees aware of the disciplinary steps, up to and including termination and legal action, against those who breach compliance laws and policies. 

Frequent Audits

As with all good business practice, implementation of reviews and audits to monitor compliance tends to improve adherence. Track enforcement assiduously to minimize more serious auditing problems. In the event that employees must be retained or terminated due to reasons of fraud or noncompliance, ensure that investigation and remediation are systemic and thorough, taking measures to improve policy implementation if such is found to be necessary.

Guard Against Fraud

To protect your clinic or hospital against healthcare fraud, reach out to our medical billing services at Aspen Ridge Medical. We adhere to strict compliance policies to maintain ethical billing procedures to prevent fraud and abuse in the healthcare practices we serve. Give us a call today to begin.