Compliance for Coding, Billing & Reimbursement: A Systematic Approach to Developing a Comprehensive Program » (2nd Edition)

While the vast majority of providers never intend to commit fraud or file false claims, complex procedures, changing regulations, and evolving technology make it nearly impossible to avoid billing errors. For example, if you play by HIPAA’s rules, a physician is a provider; however, Medicare requires that the same physician must be referred to as a supplier. Even more troubling is the need to alter claims to meet specific requirements that may conflict with national standards. Far from being a benign issue, differing guidelines can lead to false claims with financial and even criminal implications.

Compliance for Coding, Billing & Reimbursement, Second Edition: A Systematic Approach to Developing a Comprehensive Program provides an organized way to deal with the complex coding, billing, and reimbursement (CBR) processes that seem to force providers to choose between being paid and being compliant. Fully revised to account for recent changes and evolving terminology, this unique and accessible resource covers statutorily based programs and contract-based relationships, as well as ways to efficiently handle those situations that do not involve formal relationships.

Based on 25 years of direct client consultation and drawing on teaching techniques developed in highly successful workshops, Duane Abbey offers a logical approach to CBR compliance. Designed to facilitate efficient reimbursements that don’t run afoul of laws and regulations, this resource —

• Addresses the seven key elements promulgated by the OIG for any compliance program


• Discusses numerous types of compliance issues for all type of healthcare providers


• Offers access to online resources that provide continually updated information


• Cuts through the morass of terminology and acronyms with a comprehensive glossary


• Includes a CD-ROM packed with regulations and information

In addition to offering salient information illustrated by case studies, Dr, Abbey provides healthcare providers and administrators, as well as consultants and attorneys, with the mindset and attitude required to meet this very real challenge with savvy, humor, and perseverance.

Case study listing

1 Overview of healthcare compliance 1

2 Structuring CBR compliance programs 11

3 Coding, billing, and reimbursement: Problem/opportunity areas 19

4 Investigation and problem solving 43

5 Development of CBR policies and procedures 57

6 Implementing changes 67

7 Developing effective training 75

8 Monitoring and corrective action 83

9 Conducting CBR baseline audits 95

10 Integrating CBR compliance into corporate compliance 105

11 HIPAA compliance 117

12 Special regulatory areas 127

13 Compliance considerations for hospitals 139

14 Compliance considerations for physicians and clinics 151

15 Special compliance audits and reviews 163

References and bibliography 179

Acronyms 185

Appendix 189

Index 199