By: Vanessa Reynolds
Health care is said to be the second most regulated industry after nuclear power. All providers, regardless of size, specialty or revenue, are subject to essentially the same regulatory environment and same sanctions for non-compliance. Common, and potentially expensive, regulatory pitfalls involve reimbursements, HIPAA and contracting.
Medicare/Medicaid and other third-party payors are more actively scrutinizing reimbursements and recouping asserted overpayments, and administrative contractors and whistleblowers abound.
Overpayments are often associated with insufficient documentation or erroneous coding. Providers should therefore familiarize themselves with payors’ documentation requirements. For example, practitioners should know the level of review and decision-making required for each evaluation and management (E&M) code, which codes require time notations, or whether there are limits on the number of times a service can be provided. Many sources of free online information are available on insurers’ and CMS and Medicare contractors’ websites and CMS listserves.