Compliance with Insurances and the Government |
At the outset, insurance companies don't normally comply to the Prompt Payment Law setup at almost every state. Most practices do not hold them accountable for it. In fact, practices seem to be okay with losing money on timely filing denials that insurance companies impose on them. Compliance law in any part of the world adheres to the concept of scienter or the knowledge of wrong doing. Compliance risk varies based on which end of the scale the practice or the individual is on the scale of knowledge of wrong doing. 'Wrong doing' touches several aspects of the practice. While its beyond the scope of what NextServices does, here are some basic questions to ask for any practice as a business: Physical compliance: Is everything constructed as per laws of the state? Is the equipment compliant? Billing compliance: Is billing reflecting exactly what is being performed? Is the billing physician the same as the rendering physician? Insurance compliance: Is the practice making refunds on any overpayments by insurance companies? Are our fee schedules usual and customary as per the region of operations? Is my insurance paying as per agreed allowed amounts? Clinical compliance: Are we coding accurately? Are we under-coding or over-coding? Staff compliance: How are my staff dealing with patients in distress? Is my staff trained to talk to patients? Are we adhering to OSHA regulations? Financial compliance: Are we meeting state and federal compliance guidelines for finances? (example, ambulatory surgery centers in New York are required to pay a percentage of earnings to the state on a monthly basis as per HCRA guidelines) |
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