decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Compliance / Inappropriate balance billing
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Article Overview
This article covers compliance issues in physician billing under Medicare and managed care arrangements, with emphasis on how participating and non-participating provider relationships affect patient financial responsibility. It is aimed at coders, billers, compliance staff, and practice administrators who need to understand the general boundaries around patient billing and the risk of violating payer rules. The discussion addresses broad policy concepts, including covered versus non-covered services, advance agreement requirements, and the fraud risk associated with exceeding payer-defined liability limits.
Why This Topic Matters
Improper balance billing can create compliance exposure, patient disputes, and allegations of fraud. Understanding the general rules helps organizations reduce billing errors and maintain alignment with payer requirements.
What You Will Learn
- How Medicare and managed care distinguish between participating and non-participating physicians
- Why patient liability limits matter in billing compliance
- What broad conditions apply when billing for non-covered services
- How payer-defined billing limits relate to compliance risk
Who Should Read This
- Medical coders
- Medical billers
- Compliance officers
- Practice managers
- Revenue cycle staff
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