A Guide to Auditing Health Care Billing Practices

Atlantic Information Servicesd monitoring techniques are one of the seven keys to an effective compliance program, according to the HHS Inspector General. And your billing practices — one of your organization's most complex, big-dollar operations — are likely to be your compliance program's Achilles' heel, since billing errors have been the basis for most of the multi-million-dollar settlements paid by hospitals and other health care organizations recently. The Guide helps you avoid problems in many of the most troublesome areas of Medicare billing — including medical necessity, upcoding, billing for services not rendered, and more.
This looseleaf guide, with monthly updates and a companion monthly newsletter, provides detailed "how-to" guidance on cleaning up your billing practices before the feds come knocking. It will walk you through the billing, monitoring and auditing steps you need to take to avoid the potentially staggering monetary penalties you may face if errors are not found and fixed. Using the Guide, you'll be able to scrutinize and tighten each step of your billing process to reduce potentially fraudulent claims.
(single volume & monthly updates and newsletters, $306 annually)

TABLE OF CONTENTS
Chapter 1: Recognizing Problematic Billing Practices
OIG billing focuses (past & present) • Billing exposures • Billing for services not documented/provided • Insufficient documentation • Double-billing • Billing for medically unnecessary services • Billing for unbundled services • Billing for inaccurate/incorrect providers

Chapter 2: Selecting Your Audit Team
Internal vs. external personnel • Team members • Communication

Chapter 3: Resources Available to Shape Your Billing Audit
Federal regulations • Medicare regulations • NCCI • HCFA directives • Coding Clinic, CPT Assistant, etc. • OIG fraud alerts • The Internet

Chapter 4: Auditing The Components of Your Billing Process
The trigger event • Registration and collection of insurance information • Documentation of patient care • Resulting for tests, equipment, supplies • Coding/ classification of diagnoses and procedures • The charge master/charge capture/charge matching/patient encounter form process • Manual edit processes • EDI interface • Denials and collections (including collection of copayments)

Chapter 5: Auditing The Components of Your IS Billing Systems
Preparing the list of data elements • Developing the audit plan • Categorizing changes made by the system • Developing an action plan

Chapter 6: Dealing With Special Billing Problems
Laboratory billing compliance issues • Hospital billing compliance issues

Chapter 7: Developing and Analyzing Your Billing Data
Focus and purpose • Sample selection • Developing the audit tools • Conducting the actual audit • Analyzing the data • Reporting on the results • Education on the deficiencies • Following up on the audit

Chapter 8: Maintaining Your Billing Process Audit
Designing and documenting the audit method
• Importance of the standards of conduct • Acting on results

Designed and Written especially for:

• Billing Directors
• Medical Records and HIM Managers
• Coding Managers
• Patient Accounting Directors
• Internal Auditors
• Compliance Auditors
• IS Directors
• CFOs and Finance Managers
• CPAs, Attorneys and Consultants

Auuthor: Ruthann Russo, JD, ART is a partner in the law firm of Russo & Russo in Bethlehem, Pennsylvania and Director of the HP3 Institute in Bethlehem. She was the founder and CEO of Cabot Marsh and President of QuadraMed's Compliance and Education Division. She has authored numerous articles on coding, billing and compliance and is the author of the book, Seven Steps to HIM Compliance. She has managed compliance billing audits for health care systems in negotiations with the OIG, designed compliance due diligence programs for health care acquisition and merger activities, created compliance programs for providers nationwide, and conducted compliance education sessions all across the country.

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