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What Is Medical Billing and Coding Compliance?

Compliance — it’s such a serious word to a medical biller or coder, and for good reason. When people in the healthcare industry speak about compliance by healthcare providers, they mean that an office or individual has set up a program to run the practice according to the regulations set forth by the United States Office of Inspector General (OIG).

The regulations are designed to prevent fraud and abuse by healthcare providers, and as a medical biller or coder, you must familiarize yourself with the basics of compliance.

Not only must you follow rules regarding how to process and bill claims, but you must also follow rules regarding the confidentiality of healthcare information. You can thank something called the Health Insurance Portability and Accountability Act (HIPAA) for setting the bar for compliance.

This act was passed by Congress in 1996 and is sometimes called the Privacy Rule. It established the first national standard for use and disclosure of health information and guarantees certain rights to individuals with regard to their healthcare.

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

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