Major Medical Bill Collection Laws

Major Medical Bill Collection Laws

The healthcare industry is just like any other commercial business, they must remain in compliance with specific state and federal regulations to remain legal. However, unlike standard commercial businesses, there are some additional rules and regulations that the healthcare industry must follow.

This is due to the fact that medical services are not only dealing with the business side of medicine but also with healthcare. This means that they are much more responsible to remain ethical on the business side as well as the medical side of the industry. On the national level, the CDC and the CMS are responsible for medical industry regulation.

In addition, CMS is responsible for governing the services for the poor, elderly, and disabled through Medicare and Medicaid and the CDC is responsible for the control of diseases. When the two come together, they create new rules/regulations, which ensure that all medical professionals are providing the most trustworthy and up-to-date services for their patients.

Basics of Medical Billing: Major Medical Bill Collection Laws

In order to get hired on as a medical biller, there are certain things you need. You must first have a high school diploma or equivalent. In addition, you must also have an associate’s degree from an accredited institution. Though it’s not required, some individuals go on to get a bachelor’s degree or even a master’s degree. A higher degree will open up more career paths/options for you.

HIPAA & National Regulations

In addition to the above, the national government has put laws in place to regulate the medical industry. The biggest of these laws is the Health Insurance Portability and Accountability Act, or HIPAA. Within the last decade, HIPAA has created lots of changes in the medical industry.

There are lots of medical billing laws and regulations associated with HIPAA. One of the most important ones is confidentiality of patient information. This means that every medical practice, clinic, hospital, and anywhere else medical treatment is received must protect their patient’s information against being leaked.

This means that each and every employee in the medical setting must sign a form stating that they understand and are committed to protecting their patients. Another requirement of HIPAA is that all patients be informed of their rights, including (but not limited to) the confidentiality of their records. In order for your information to be released to someone or another medical practice, you must sign a form stating that you give your permission.

The enactment of HIPAA 5010 is another important aspect of the HIPAA legislation. This was put into place due to the increase in digital records being kept and protects all electronic patient data as well.

Finally, according to HIPAA, ICD-10 codes must be used, which allow the reporting of patient diagnoses to be more specific.

Ethical Medical Practice Standards

On the local level, medical professionals and offices must operate within specific standards of ethical medical practice. This is including the way the medical professional and staff communicates with their patients, the way they treat their patients in the office, and a commitment to provide the best care to all patients, no matter what.

While many unethical practices are not necessarily illegal, they can cause a provider and his office to be taken to court and held liable. For example, let’s say a patient is not treated to the best of the ability of the provider due to his/her race or sexual orientation. The provider would be held responsible for anything that happened to the patient because he did not provide adequate medical care.

In the case of a hospital or large medical group, there may be an ethical committee that holds the physicians accountable. They will gather in certain situations to determine the proper ethical medical treatment of their patients. This will help to avoid problems in the future and litigation.

Insurance Contracts

One of the largest governing documents in a medical office is the contracts the provider has with various insurance companies. These regulate a variety of topics from the length of time a patient can wait in the waiting room to the way claims are billed and submitted.

The provider is required to sign a contract with each and every insurance company that he/she accepts. This contract places regulations on the practices of the physician and negotiates the payment amounts for each code that is billed by the provider.

This contract also includes information regarding the ways the office of the provider will treat the patients in the office. Typically, the office staff must act within the standards of ethical medical practice. The contract will also list critical billing rules that the office must follow. One of which refers to balance billing.

Balance Billing

When a contract with an insurance company is signed by a medical provider, he or she is agreeing to accept a certain payment/percentage for his services. The amount that he or she bills above the agreed upon amount must be written off. The physician is not able to bill the patient for any amount above the negotiated rate. If the medical provider bills a patient like this, it’s known as balance billing and is illegal.

Medical Billing Fraud

One of the biggest problems in the medical industry is medical billing fraud. This is when the medical office is billing for services that are inaccurate or have not been performed. The insurance company ends up paying more, which fattens the physician’s wallet. This is a major offense and is not one that is taken lightly by the federal government. Depending upon the extent/amount of fraud, the provider may end up having to pay a huge fee or even spend some time in jail.

Good Business Practices

Besides all of the medical bill collection laws that a provider’s office must follow, there are also good business practices that should be followed. Most of the time, these are not federally or even locally governed, but they do relate to the way patients are treated and the quality of services that are provided.

No matter what business you are working in, it’s critical that you are providing the best care/service possible and you are treating your consumers the way you wish to be treated.

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