Guarding Your Practice: Prioritizing Compliance in Medical Billing

In the intricate landscape of medical billing in the United States, healthcare providers are entrusted with a multifaceted mission that transcends patient care. It involves navigating an intricate web of evolving legal standards, intricate regulations, and the ever-present specter of medical billing fraud. Recent data underscores the gravity of the situation, with the U.S. government collecting an astonishing $26.8 billion in healthcare-related civil settlements and judgments from 2013 to 2022. This alarming sum underscores the pressing need for healthcare providers to prioritize compliance and diligently select billing partners. In this blog, we explore the imperative of medical billing compliance, emphasizing the critical need for healthcare practitioners to skillfully navigate these complexities.

Enforcement Action:

Over the past decade, the Health Care Fraud Strike Force, through 16 strike forces across 27 districts, has brought charges against over 5,000 doctors and healthcare practitioners. These individuals collectively billed federal health care programs and private insurers billions of dollars. Today, many of them find themselves behind bars or facing the potential revocation of their licenses as their cases progress through the judicial system.

Medicaid Faulty Billing or Fraud Dollars:

Recent data paints a concerning picture, with Texas leading the way with a staggering $219.9 million in Medicaid fraud dollars in 2022. This is closely followed by California at $108.5 million, Florida at $88.3 million, Massachusetts at $71.3 million, New York at $58 million, Washington at $47.8 million, Arkansas at $42.6 million, and more. These statistics underscore the rampant issue of healthcare fraud across the nation.

Common Faulty Billing Practices:

Among the most prevalent issues in medical billing are the submission of multiple claims for the same service, phantom billing, billing for services or supplies never received, and unbundling services by submitting multiple bills for the same service. These practices not only tarnish the reputation of healthcare providers but also expose them to the risk of legal actions, leading to the potential demise of their careers.

The Role of Medical Billing Companies:

In their quest for financial stability and compliance, many healthcare providers turn to medical billing companies. However, a significant concern for everyone is the pricing of these services. As the age-old adage goes, “You get what you pay for.” Regrettably, a majority of inshore and offshore billing companies may lack the necessary expertise and communication channels to rectify billing mistakes, leading to compliance issues. And when you sign up with companies prioritizing pricing and not the compliance and quality, it tantamount to signing your own death warrant.

Lack of Guidance from Billers:

These billers often lack the means to coach healthcare providers on the correct billing procedures. They process bills without offering the necessary guidance, potentially leaving practitioners oblivious to the consequences. An illustrative case is that of a New Jersey cardiologist currently facing federal charges for improper billing and fraud. He chose to collaborate with a lesser-known billing company primarily due to cost considerations, despite their lack of expertise in adhering to billing regulations. A colleague who knows the cardiologist personally vouches for his integrity, asserting that he didn’t commit fraud. However, the issue arose because the cardiologist, although seeing all his patients, failed to maintain adequate records reflecting the level of care he provided. This situation has turned into a nightmare for him and his family.

The Importance of Compliance:

Other healthcare professionals believe that if federal authorities were to investigate today, nearly 90 percent of doctors might find themselves in trouble, primarily because they are not following the correct billing procedures. Many lack even basic knowledge about the monitoring of billing timing, and they are unaware that their billing practices could be under scrutiny in today’s high-tech digital surveillance environment.

Collaborative Meetings with Billing Companies:

It’s crucial to note that billing companies cannot be held responsible for these issues, as most contracts they enter into with providers clearly absolve them of such responsibilities. However, healthcare providers should establish regular meetings, initially on a weekly basis and later, perhaps, monthly, or when their billing processes become more streamlined. These meetings help providers stay informed about and compliant with changing regulations.

Drawing from our 24 years of experience, our first step in assisting practices is to ensure their compliance. We’ve had to suspend business relationships with clients who were unwilling to work with us on compliance issues. In one of the most recent cases, we were on the verge of terminating a contract with a major hematology group until they began following the correct procedures for billing. Here are some of the mistakes they were making:

For instance, they were advising patients to quit tobacco use but failing to document the information regarding the impact of smoking, assess the patients’ willingness to attempt quitting, and provide methods and skills for cessation or medication management for smoking cessation drugs. They also lacked records of resources provided or notes indicating the set quit date and follow-up arrangements, all of which are essential for comprehensive and compliant documentation.

The Importance of Comprehensive Documentation:

Incomplete Documentation: Inadequate progress notes and incomplete documentation are common pitfalls for medical practitioners. These shortcomings can lead to lost revenue and a decline in patient care quality. Healthcare providers must prioritize comprehensive and compliant documentation.

Cybersecurity Concerns:

Healthcare providers often overlook the credentials of the medical billing companies they engage with. This negligence can lead to cybersecurity breaches, potentially resulting in significant HIPAA compliance violations.

Additional Audit Concerns:

Copy-pasting can be a valuable time-saving tool, but it has raised significant concerns regarding the accuracy, completeness, and integrity of our patient records. In certain instances, providers have been observed copying large portions of documentation without adequately tailoring it to the specific patient encounter. This practice not only jeopardizes patient safety but also poses substantial compliance risks.


In summary, medical billing compliance goes beyond following rules; it’s about upholding the integrity of healthcare and ensuring that patients receive the quality care they deserve. To protect against the legal consequences of non-compliance, healthcare practitioners must carefully select billing partners, maintain accurate documentation, and prioritize data security. By remaining vigilant and informed, healthcare providers can effectively navigate the complex world of medical billing and safeguard their practices. The choice of a billing company is pivotal in this endeavor.

About author:

Anne Portel is a Founder of Everest AR Inc. She has been working in the medical billing industry for more than three decades. She can be reached at an**@ev*******.com 






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