Healthcare Regulatory Compliance & the Revenue Cycle
Connect regulatory compliance requirements to revenue cycle operations and understand the consequences of non-compliant billing.
📘 Reading Lesson
Lesson Notes
Read through the key concepts before you try the challenge.
Compliance Programs in Healthcare
Healthcare organizations are required to maintain formal compliance programs that prevent, detect, and correct violations of applicable laws and regulations.
- OIG (Office of Inspector General) compliance guidance
- False Claims Act — penalties for knowingly submitting fraudulent claims
- Anti-Kickback Statute — prohibits payment for referrals
- Stark Law — prohibits physician self-referral for designated health services
Compliance and the Revenue Cycle
Billing compliance means that every claim submitted accurately reflects the services documented in the patient record. Upcoding, unbundling, and billing for services not rendered are all forms of fraud.
The False Claims Act allows the government to recover three times the amount of a fraudulent claim plus additional penalties per claim. Healthcare fraud is taken seriously.
Challenge
Apply what you've learned in this lesson.