• Electronic Medical Records (EMR)
• Scheduler with Eligibility Test
• Compliance Management
  + Core Elements
  + Regulatory Risks
  + Auditing and Monitoring
  + Documentation Guidelines
  + Audit Exposure Evaluation
• Data Entry and Payment Posting
+ Charge Entry
• Superbill Interface
• Variety of Claim Entry Formats
• Fax
+ Demographic Data Entry

• Coding
  + Coding Consistency
  + Discovery of Undercoding
• Claim Submission to Payers
• Patient Invoicing
• Follow Up
  
+ Discovery of Underpayment

• Transparency, Analysis and Reporting
• Quality Control
  + Billing Process
  • Payment Distributions
  • Days in A/R
  + Claim Validation
  + Patient Eligibility Testing
  
• Data Center
  

OIG lists the following items as specific regulatory risks most frequently subject to investigation and audit:

1. Billing for items or services not rendered as claims
2. Submitting claims for supplies and services that are not reasonable and necessary
3. Double billing
4. Billing for non-covered services
5. Failure to properly use coding modifiers
6. “Clustering” (using only a few codes on the theory that it will average out)
7. “Upcoding” (using a higher reimbursement code than the code reflecting the service rendered)
8. Inappropriate balance billing (billing Medicare beneficiaries for the difference between the total provider charges and the Medicare Part B allowable amount)
9. Routine waiver of co-payments and billing third-party insurance only
10. Discounts and professional courtesy
11. Improper billing for incident-to services
12. Improper reassignment of physician billing numbers
13. Failure to refund credit balances due to patients and payers
14. Billing for services provided by unqualified or unlicensed clinical personnel

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* Much of the material for this section of the website follows “Understanding Compliance: A Program Guide Based on the OIG 2000 Guidance,” by R. Saner, M. Spindel, A. Nordeng, Powers, Pyles, Sutter & Verville, P.C., MGMA, 2000