Patient Care Facility Accreditation Guide

The Claims and Billing Compliance Standards support compliance with CMS and OIG billing guidelines. Depending on business size and scope, the organization is expected to develop a compliance program consistent with the OIG Compliance Program Guidance for the DMEPOS Industry.

The Standards parallel five critical elements:

1. A formal claims and billing compliance program based on policies and procedures.

2. A qualified and trained individual is responsible for maintaining the compliance program. 

3. Appropriate staff are properly trained and educated on claims development and billing. 

4. Auditing and monitoring mechanisms to ensure consistent compliance.

5. Appropriate response to detected problems and corrective action.

The compliance program should guide the organization in preventing inappropriate billing, provide ongoing education, monitor performance, identify areas needing improvement, and document corrective actions.                                                                                                                                                    

CB.1

You must administer a claims and billing compliance program with written policies, procedures, and standards that describe your compliance with federal and state policies.

Tip

Many national associations and agencies provide education programs in claims and billing compliance. 

CB.2

You must designate a qualified and trained individual to be responsible for maintaining the claims and billing compliance program.

Tip

Your policy must identify the specific staff member responsible for claims and billing and document their qualifications and training with a job description, meeting minutes, attendance logs, course certificates or in-service agendas.

CB.3

You must provide claims development and billing education for all staff involved with or responsible for claims and billing. You must have documentation that you have implemented practices to prevent and control fraud, waste, and abuse.

Tip

Your designated staff members must be educated and trained in claims development and billing particular to job duties and responsibilities related to the compliance program. Document this education with meeting minutes, attendance logs, course certificates, or in-service agendas. Use the Billing Education Documentation form in the online Resource Kit to document this information.

CB.4

You must establish ongoing file-auditing and monitoring policies and procedures for clinical and financial records to ensure consistent compliance with all applicable federal, state, and private-payer healthcare plans.

CB.4.1

You must have written policies and procedures that ensure investigations of suspected or actual noncompliance are handled appropriately, and any necessary corrective action is taken.

Tip

You must have a plan that addresses how you conduct internal investigations of suspected noncompliance. This plan should include:

• A time limit for closing an investigation of suspected claims and billing noncompliance
• Options for corrective action after determining that an act of noncompliance has occurred, including disciplinary action, a review of existing policies and procedures, and employee training
• An indication of when it would be necessary to conduct a noncompliance investigation by an outside, independent investigator
• An indication of how and when to refer an act of noncompliance to CMS or law enforcement authorities
• An indication of when to report the suspected noncompliance to ABC as required by the Code of Professional Responsibility