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Identifying barriers to billing compliance.

Daniel P Lorence¹, Ibrahim Awad Ibrahim

¹Pennsylvania State University, University Park, PA, USA.

Journal of Health Care Finance

|September 12, 2003

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Aggressive enforcement of health care fraud regulations reduces fraud, but institutional non-compliance persists. Understanding compliance barriers is crucial for effective health care claim management.

Area of Science:

Health Care Management
Health Law
Medical Economics

Background:

Federal regulators are increasing enforcement against health care fraud, particularly over-reimbursement.
Stricter penalties aim to deter fraudulent practices and incorrect reimbursement claims.

Purpose of the Study:

To investigate barriers to compliance management in health care claims processing.
To assess the impact of enforcement regulations on fraud reduction and compliance.

Main Methods:

National survey of accredited US health information managers.
Analysis of compliance actions from over 16,000 health care managers.
Examination of demographic, practice setting, and market characteristic variations.

Main Results:

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Publication of compliance regulations significantly reduced fraud.
Widespread non-adoption of proper billing compliance measures persists despite prosecution risks.
Compliance management benchmarks vary significantly across settings and markets.
Increased publicity on billing procedures can lead to "institutional non-compliance".

Conclusions:

Compliance actions must consider institutional and industry-wide influences.
Effective fraud control requires addressing persistent non-compliance and varying benchmarks.
Understanding compliance barriers is key to improving health care payment integrity.