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One area of regulations affecting most health care providers is the billing of federal and state health plans, in particular, the Medicare and Medicaid programs. The federal government and many states continue to aggressively pursue enforcement action. Areas of special concern are: - Assignment of inappropriate diagnosis-related groupings (DRG)
- Claims for outpatient services that should have been considered part of an inpatient stay, commonly known as violations of the 72-hour DRG billing window
- Incorrectly coding costs in cost reports or otherwise preparing inappropriate or false cost reports
- Failure to refund credit balances
- Non-arm's-length transactions
The related rules and regulations are extensive and complicated, and health care providers are responsible for determining that the services rendered, related documentation and billing comply with the rules and regulations. Health care providers should review written corporate compliance programs frequently to ensure that procedures and controls to prevent, detect and correct wrongdoing within the organization are up to date. Such a program should also include standards of conduct, operational policies and employee training requirements.
This commentary was written by Brian Schebler, director of services to the public sector. Schebler focuses on public sector entities, including monitoring and reporting developments of professional standards. He is a certified government financial manager, who develops and delivers CPE and produces firm manuals. He serves on the U.S. Government Accountability Office Advisory Council on Government Auditing Standards, the AICPA Government Audit Quality Center Executive Committee and on the AICPA State and Local Government Expert Panel.
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