carrying out one's responsibilities with integrity,decency,respect,honesty,competence,fairness and trust.
billing related cases are based on HIPAA and false claims act
HIPAA title I
HIPAA title II
false claims act
federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. Rewards and protects those involved in whistle blower cases.
national correct coding initiative (NCCI)
developed by CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of part B health insurance claims.
NCCI column1/column2 edits
identifies code pairs that should not be billed together because one code includes all the services described by another code.
NCCI mutually exclusive edits
identifies code pairs that for clinical reasons are unlikely to be performed on the same patient on the same day.
knowingly and intentionally deceiving or misrepresenting information that may result in unauthorized benefits.
submitting a claim for a service or procedure performed that was not medically necessary to treat the patients condition.
physicians are legally responsible for their own conduct and any actions of their employees.
Errors and omissions insurance
protection against loss of monies caused by failure through error or unintentional omission on the of the individual or service submitting the insurance claims.
documentation on the patients social and medical history,family history,physical examination findings,progress note, radiology and lab results,consultation reports and correspondence to patient.
reason for documentation
avoidance of denied or delayed payments,enforcement of medical record keeping rules by insurance carriers,subpoena of medical records ,defense of a professional liability claim.
retention of medical records
most physicians are required to retain records indefinitely; deceased patient records should be kept for at least five years. governed by the state and local laws The rules may vary from state to state