As a Medical Biller, it is important to know the main Governing bodies who will enforce laws and standards. Knowing what each of these agencies does is helpful when working on medical billing in your practice, and what standards need to be adhered to.

In healthcare,  the word ‘compliance’ means that a Doctors office, a hospital or any other type of  Healthcare provider has set up a program to run the practice according to the regulations set forth by the United States Office of Inspector General (OIG).

Regulations are designed to prevent fraud and abuse by healthcare providers. As a medical biller or coder, it is very important to familiarize yourself with the basics of compliance.

It is important to follow rules regarding how to process and bill claims, and also the rules regarding the confidentiality of healthcare.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (also sometimes called the Privacy Rule) was established as the first national standard for use and disclosure of health information and guarantees certain rights to individuals with regard to healthcare.

HIPAA outlines how certain entities (a health insurance plan, a medical clearinghouse, or healthcare provider) can use or disclose personal health information (often called PHI). In addition, under HIPAA, patients must always be allowed access to their medical records.

The United States Department of Health & Human Services (HHS) is the primary U.S. government agency responsible for protecting the health of Americans. Medicare and Medicaid, both a part of the Centers for Medicare & Medicaid Services (CMS), are two of this agency’s programs, and together they provide healthcare insurance for millions of Americans.

The OIG protects the operations of the HHS, including programs under other HHS institutions, including the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the Food and Drug Administration (FDA).

Finally, The American Medical Association (AMA) develops, maintains, and owns the copyright to Current Procedural Codes (typically known as CPT codes), determines what the code represents. The CMS works with the AMA to determine correct coding edits and which codes are incidental to others.

As you can see, there are many different US Government departments working together to protect the rights of patients, and ensure ethical medical practices in the United States.

Having a clear understanding of what each agency stands for and protects is helpful when working on medical billing in your practice, and what standards need to be adhered to.