Billing Compliance Conflict? Navigate It with Confidence
Billing Instructions Raising Concerns? Here’s a Pro-Level Playbook
Written by: Toni Elhoms | Alpha Coding Experts
In the complicated world of pay-and-chase healthcare reimbursement, medical billing is not just a back-office support function, but rather a regulatory landmine for healthcare organizations! From Stark Law to the False Claims Act violations, billing errors can lead to significant legal and financial consequences for healthcare organizations. So, what happens when your organization’s leadership issues billing instructions that don’t sound right? Below are some Pro-Tips outlining how to navigate the situation professionally, ethically, and in alignment with published authoritative guidance.
Pro-Tip #1 – Pause and analyze the billing instructions thoroughly and objectively. Ask the following questions when analyzing the billing instructions for accuracy and compliance:
- What type of services are involved that would be billed?
- What are the rendering provider and supervision requirements of the services? Who will be rendering the services? Who will be supervising the services?
- What billing codes (CPT/HCPCS/ICD10) would be used?
- Are modifiers involved? If so, the relevant NCCI edits will need to be queried to ascertain billability and compliance requirements.
- Which place of service is applicable?
- Which reimbursement fee schedule would the services be paid under?
- Do the billing instructions relate to incident-to billing?
- Do the billing instructions relate to split/shared services?
- Do the billing instructions relate to Telehealth or Digital health?
- Do the billing instructions involve any potential Stark Law violations?
- Do the billing instructions involve any potential Anti-Kickback Statute violations?
- Do the billing instructions involve any potential False Claims Act violations?
- Do the billing instructions involve any potential Beneficiary Inducement violations?
Pro-Tip #2 – Identify the specific compliance risk area(s) involved. Do the billing instructions involve upcoding or unbundling issues? Are codes being selected to maximize reimbursement rather than reflect the actual services rendered? Are services being billed under a physician when performed independently by a non-physician practitioner? Is there documentation to support the services as rendered? Has medical necessity been established and met to the full extent? Could financial arrangements or referral patterns be influencing billing and treatment decisions? Check out the OIG advisory opinion database as it includes regular compliance guidance updates that can be an invaluable resource for healthcare organizations when assessing compliance risk.
Pro-Tip #3 – Document your compliance concerns clearly and factually and make sure to do so in writing. Avoid jumping to conclusions or making accusations. Create a summary of the billing instructions from both your point of view and from the leadership’s perspective. Make your case by including citations to specific regulations, billing manuals, and authoritative sources that you believe conflict with the billing instructions provided to you. Come to the table with receipts, which include examples of past or present audit findings that support your position. It’s imperative to use neutral and professional language because it is entirely possible for this documentation to be reviewed later down the road by compliance auditors, investigators, or legal counsel in connection with a civil lawsuit or criminal matter. You would be surprised what the experts, investigators, and attorneys involved in a case get to review in discovery. I have personally seen entire cases hinge on questionable and suspicious written email correspondence about a compliance issue that is now the epicenter of a legal dispute.
Pro-Tip #4 – Initiate a respectful dialogue with organizational leadership. Approach the decision-maker with the goal of seeking clarity and not confrontation. For example, “I have reviewed the billing guidance for [service/procedure], and I have a few compliance concerns based on [specific CMS or OIG guidance]. Could we discuss whether there’s flexibility or another interpretation we might consider ensuring we remain within regulatory compliance boundaries?” In this example, you are not just raising a red flag but also positioning yourself as a partner in compliance risk mitigation.
Pro-Tip #5 – Involve compliance and legal counsel if necessary. If the informal discussions to resolve the disagreement fail or if the instruction clearly directs you to engage in fraudulent or non-compliant billing practices, you will need to escalate this situation to the compliance department/officer, refer the matter to the organization’s compliance hotline, and possibly even report it to the OIG’s hotline. Most healthcare organizations have access to either internal or external legal counsel and this should be explored if necessary. Keep in mind that whistleblower legal protections may apply if you face any retaliation for reporting a legitimate compliance concern.
Pro-Tip #6 – Promote proactive compliance education and policy clarification throughout the entire healthcare organization. Ongoing education is one of the best defenses against billing disputes because of the visibility and open communication. Be sure to advocate for regular coding and compliance training for all staff, ensure clear compliance policies and procedures that adhere to CMS and payer requirements, and routinely monitor them through audits and investigations to identify issues early on.
Disagreeing with billing instructions is not just a professional challenge, but an opportunity to reinforce the ethical and compliance backbone of the healthcare organization. With clarity, respectful communication, and grounding in regulatory guidance, you can successfully navigate these situations while protecting patients, healthcare providers, and the organization itself!
Ms. Elhoms’ expertise extends to both inpatient and outpatient coding, compliance, billing, and reimbursement. She has extensive medical coding, billing, and auditing experience in the following specialties: orthopedic surgery, spine surgery, neurosurgery, cardiology, interventional cardiology, general surgery, oncology, hematology, internal medicine, family practice, geriatrics, pediatrics, pain management, neurology, urology, hospital medicine, critical care, and other practice areas.
