By: Christopher A. Parrella, Esq., CPC, CHC, CPCO
Parrella Health Law, Boston, Ma.
A Health Care Defense and Compliance Firm

In the complex landscape of healthcare compliance and Medicare regulations, it’s crucial for providers to stay informed and vigilant, especially when it comes to the use of outsourced services such as overseas billing agents. The Centers for Medicare & Medicaid Services (CMS) underscores the importance of this vigilance, particularly in the realm of eligibility verification and claim status inquiries.

The Imperative of Using IVR and eServices
CMS mandates that providers, billing companies, and outsourced agencies utilize the Interactive Voice Response (IVR) system or the Palmetto GBA eServices tool for these purposes. Recent trends, however, reveal a concerning pattern. An increasing number of billing companies and outsourced agencies are either neglecting or outright refusing to use these mandated systems. The problem is exacerbated when these entities display a lack of basic understanding of Medicare coverage and billing requirements, leading to repetitive and unnecessary inquiries.

The Impact on Your Practice
It’s essential to recognize that these outsourced entities are, in effect, representatives of your practice. Patterns of non-compliance or inefficient use of resources like the IVR or eServices tools not only reflect poorly on your practice but also strain the system. Palmetto GBA has noted patterns of generic, scripted questions that do not pertain directly to specific provider claims. Such practices, which could be resolved through the use of tools like the IVR, the Portal, or the official websites, lead to inefficiencies and potential liabilities.

Best Practices for Providers
As a provider, there are several steps you can take to mitigate these risks:

• Ensure Access to Vital Information: Provide your vendors with access to necessary Medicare remittance and appeal notices relevant to the services and claims they handle.
• Educate Your Vendors: It’s vital that your outsourced agencies and billing companies have staff who are well-informed about Medicare rules and regulations. They should be encouraged to utilize the resources available on the Palmetto GBA and CMS websites.
• Mandate the Use of Tools: Stress the importance of using the IVR and eServices tools for verifying eligibility and claims status.

The Overarching Responsibility for PHI
A critical aspect that requires unwavering attention is the protection of Medicare beneficiary Protected Health Information (PHI). The responsibility of safeguarding PHI lies squarely with the provider, not the outsourcing agency or billing company. In the event of a PHI disclosure, the provider faces potential financial penalties. Therefore, it is crucial to ensure that your outsourced services have robust processes in place to protect PHI effectively.

Conclusion
In conclusion, while outsourcing can be an efficient way to manage aspects of Medicare-related work, it comes with significant responsibilities. Providers must ensure that their vendors are competent, compliant, and using the mandated tools efficiently. Keeping abreast of these requirements and ensuring adherence to them is not just a matter of regulatory compliance, but also a reflection of your commitment to quality healthcare delivery and patient data protection.

At Parrella Health Law, we are committed to guiding our clients through the complexities of healthcare law with expert advice and comprehensive solutions. If you have any questions about this blog post or require assistance with healthcare defense and compliance matters, please don’t hesitate to contact us. We are ready to speak with you or respond to any emails sent to 857-328-0382.

Christopher Parrella, ESQ, CPC, CHC, CPCO, is the founding partner of Parrella Health Law in Boston, Mass. The firm focuses exclusively on healthcare defense and compliance matters. Chris also travels the country on behalf of a wide range of healthcare organizations, lecturing on a variety of health care enforcement and compliance topics. Chris is one of a handful of health care attorney’s that are also Certified Professional Coders (CPC) and is a member of the AAPC’s National Legal Advisory Board and Ethics Committee.  He is also a Certified Professional Compliance Officer (CPCO) and Certified in Health Care Compliance (CHC.)