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Compliance Program

Compliance Program

Standard 3 — Proper Coding, Billing, and Patient Accounting

University personnel involved in the coding, billing, documentation and accounting for patient care services for the purpose of billing government, private or individual payers must comply with all applicable state and federal regulations and campus policies and procedures for detecting and preventing fraud, waste and abuse.

  • The university will bill only for services actually rendered and shall seek the amount to which the university is entitled. The university does not tolerate billing practices that misrepresent the services actually rendered.

  • Supporting medical documentation must be prepared for all services rendered. University personnel shall bill on the principle that if the appropriate and required documentation has not been provided, then the service has not been rendered.

  • All services must be accurately and completely coded and submitted to the appropriate payer in accordance with applicable regulations, laws, and contracts and campus policies and procedures. In all cases, federal and state regulations take precedence; however, campus policies and procedures must accurately reflect those regulations.

  • All patients shall be consistently and uniformly charged. Discounts will be appropriately reported, and items and services consistently described so that comparability can be established among payers.

  • Government-sponsored payers shall not be charged in excess of the provider’s usual charges. Any questions regarding the interpretation of this standard should be directed to the chief compliance officer or university legal counsel.

  • Billing and collections will be recorded in the appropriate accounts. Credit balances must be processed in a timely manner in accordance with applicable rules and regulations. When the cost report process identifies any credit balances, university personnel shall direct those issues to the academic health center, the health system's accounting or risk management departments, or other personnel responsible for patient accounts.

  • University personnel should be aware of the existence of system-wide and campus Professional Fee Billing Guidelines and Clinical and Laboratory Billing Guidelines. These Guidelines, available through the campus Compliance Office, provide for the policies and procedures to be followed when the university bills payers for professional fees and laboratory services. University personnel responsible for coding, billing, and documentation should be knowledgeable about university policies and procedures, federal and state regulations regarding those activities. The university shall provide these individuals with opportunities for training to allow them to accurately code, document, and bill according to federal and state regulations and the university’s policies and procedures. Management at each academic health center campus should ensure that appropriate evaluation processes have been established to assess whether university personnel understand and carry out correct procedures.

  • Elective procedures that are not covered by governmental or private payer can be provided. However, before providing any elective services, the provider must inform the patient that these services may not be covered. The provider should obtain the patient's agreement to pay for the services if payers deny the claim. A patient has the right to have a claim submitted even if services are excluded from coverage.

  • An accurate and timely billing structure and medical records system is critical to ensure that university personnel can effectively implement and comply with required policies and procedures. Demonstrated lapses in the information and billing systems infrastructure should be remedied in a timely manner by the campus executive management team, other designated university personnel and billing entities.