Practical Proactive Ideas

How do I review my practice process for regulatory compliance?

1. Stay updated on new guidelines for your specialty (CMS List service/ MLN publications, other)

Review of documentation

Review of coding practices

2. System review by outside auditor, or internally if you have the skill sets, to determine area(s) for audit and review

Sounds easy enough but what steps can you take to using the tools at hand. One solution is to use the same technique the insurance payers use. Insurance payers are aware of the complexities that exist, which is why they offer services such as benefits verification, pre-certification, explanation of benefits with specific remark codes, corrected claims submission and appeal. The key for healthcare organizations is to take the knowledge they gain through these interactions with insurance payers and apply that information to their global practice.


Functional billing -There are a couple of ways this can be set up? If you have a sophisticated practice management system (PM), it will have the capable to track denials identified on your explanation of benefits (EOB) by ANSI codes. It will provide you with a tremendous wealth of knowledge regarding compliance errors and/or processing problems in your practice. If you do not have a PM system that will track ANSI code errors, a manual process will need to be utilized. Well worth the time and effort to perform. Constantly review claims internally for accuracy and validity for payment. CMS has valuable tools to assist you.


Periodic sample audits - are the most valuable tool your organization can use to ensure compliance as well. By having experts evaluate your services, processes, and documentation on a regular basis. The government has suggested a benchmark audit of at least 5 records per federal payer per provider in the group. If you have the internal skill sets within the organization this can be accomplished with limited financial investment. Regardless of doing a review in-house or with outside help, it MUST be done. There is no longer the option of not knowing. Not only is the government reviewing your data but so are the commercial carriers.


Renee M. Brown, CMIS, ACS-EM, CHA is president and managing partner of Medical Practice Consultants, Inc. (MPC). She is a Certified Healthcare Auditor (CHA), as a Certified Medical Insurance Specialist (CMIS), Advanced Coding Specialist for Evaluation/Management services (ACS – EM) as well as a trainer to Medical Group Management Association (MGMA) and American Academy of Professional Coders (AAPC) and large hospital organizations throughout the United States.


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