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The Possible Consequences of Not Being in Full Compliance

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There are a number of laws and regulations your practice must strictly follow to ensure it is fully and accurately reimbursed for patient care services. These laws and regulations not only monitor payment accuracy, but are also in place to prevent fraud and abuse and to preserve patient privacy and security. If you don’t always comply with them, you risk your revenue cycle being impacted – or worse being fined. You simply can’t afford not to be in compliance.

The vast majority of physician practices strive to be compliant and can attest to the huge challenge behind the effort. This is because keeping up with the constantly changing laws and regulations, along with the updates to medical necessity, requires a significant amount of staff resources that many practices simply don’t have. It is not surprising that medical necessity almost always ranks among the top 10 causes of Medicare denial, especially given how frequently payer policies and National Correct Coding Initiative (NCCI) edits change.

Although the rules are a huge part of the compliance equation, they are not the only variable to making sure your practice is compliant. You also have to make sure clinical documentation sufficiently justifies specific treatments and services. Submitting claims that don’t support medical necessity will lead to rejections and denials. If your practice consistently submits claims that are rejected or denied, your organization is more likely to be flagged for a potential audit, which also results in a time- and resource-intensive experience.

There is some good news though—technology can help your practice manage the changing laws and regulations to ensure your practice is compliant. For example, claims scrubbers can identify bundled codes and alert you to make revisions, allowing you to correct a claim before you submit it for reimbursement. These technologies are typically supported by an extensive staff whose job is to remain current with new or updated rules and regulations, so users of the technology are provided a safety net from potential non-compliance.

Investing in technology does require a monetary commitment, but the benefits usually outweigh the costs. Being confident in your compliance and avoiding possible audits can save your practice valuable time and money and ensure the collection of accurate payments for rendered medical services occurs, contributing to its long-term financial health.