‘Stop Worrying’: Billing Specialist Offers Seven Elements for Effective Compliance Program


Carol Yarbrough recognizes that compliance can be a scary avenue for many in the healthcare industry.

“When I was a compliance officer type person, people would avoid me on the street … they don't do that anymore,” Yarbrough joked during a recent webinar discussion on billing practices for hospital and clinic professionals.

Yarbrough, a specialist in federal and state regulatory billing and reimbursement guidelines, recently led the virtual webinar for the Southwest Telehealth Resource Center.

“You know, I know we are all anxious. … It's been an anxiety-inducing several years. What do we bill? How do we bill it? When do we bill it? What's going to happen tomorrow?” Yarbrough said, referring to the Public Health Emergency guidelines issued during the pandemic, and the extension deadlines issued every 60 days.

Before Yarbrough went through each of the seven elements or steps for the presentation, she listed the Office of Inspector General’s Top 10 Reasons for having seven steps to guide a compliance practice for billing procedures at a hospital or clinic.

The OIG’s Top 10 Reasons for the 7 Steps, listed by Yarbrough:

  1. Safeguards organizations legal responsibility
  2. Demonstrates to employees and community commitment to good corporate conduct
  3. Identifies and prevent criminal/unethical conduct
  4. Improve quality of patient care
  5. Create a centralized source for healthcare regulations
  6. Develops methodology/encourages employees to report problems
  7. Develops procedures to allow prompt investigation
  8. Initiatives immediate and appropriate corrective action
  9. Reduces orgs exposure to civil penalties and criminal sanctions
  10. In some hospital the OIG allows for a compliance program to be included in the cost (Not for government imposed or CIA)

Yarbrough’s Seven Steps

Step 1: Implement written policies, procedures, and standards of conduct.

“You probably already have this,” Yarbrough said, adding that there are many resources available to help guide preparing a code of conduct.

Yarbrough recommended looking at the AMA Code of Ethics as a starting point to look at where to start or to reflect on your current code.

Other parts of step one need to include designating a compliance officer, and a compliance committee. Some often to choose to hire an attorney, but Yarbrough says she thinks it’s best to hire someone who has worked their way up through the hospital and understands what’s going on at the clinic level. If that person has a Certificate in Healthcare Compliance, that’s better situation, too.

“I've got a certification in healthcare compliance myself,” Yarbrough said. “It gives you some street cred.”

Step 2: The Committee

Yarbrough said when putting together a compliance committee, even if compliance organizations don’t include this in their recommendation list, she’d consider thinking about adding a billing coder or biller to the committee.

The remaining list is straight out of C Suite: Chief Financial Officer, Chief Accounting Officer or Controller (if your organization has one), General Counsel, HR Director, IT Director, Chief Information Security Officer or Chief Privacy Officer, and Head of Procurement (again, if your organization has one).

Step 3: Conduct effective training and education.

Yarbrough recommends making it part of synchronous training that’s included with all new hire onboarding or annual training.

“People tend to pay more attention when it is part of synchronous training,” she said.

Step 4: Develop effective lines of Communication using what your organization may already have, such as listserv, bulletins/newsletters, and quarterly meetings with leadership and unit directors.

Step 5: Conduct Internal Auditing & Monitoring

“You do need to do your own auditing and monitoring,” Yarbrough said, recommending compliance folks look at an internal audit program from the University of Oregon that looks closely at selection, planning, fieldwork, reporting and follow up.

“Call them. Find out what you can appropriate with credit,” Yarbrough said. “As the compliance officer it’s important to get permission first.”

Step 6: Enforce standards via well-publicized disciplinary guidelines.

One place to start if you need help is the Health Care Compliance Association, which has a Compliance 101, Fourth Edition available.

According to Yarbrough, the OIG calls for the written standards of conduct to address the procedures for handling disciplinary problems and those who will be responsible for taking appropriate action. Intentional or reckless noncompliance is to be punishable with “significant sanctions,” which can range from oral warnings to suspension, privilege revocation (subject to any applicable peer review procedures), termination or financial penalties as appropriate.

Step 7: Respond promptly to detected offenses and undertake corrective action

“You know not all whistleblowers want monetary gain,” Yarbrough said. “Most whistleblowers want to still work.”

Consider adding an anonymous way for employees to report issues. If a billing issue is discovered with Medicare – overpayment or underpayment, don’t wait to address or report it just because you can since the lookback period is six years.

Yarbrough’s presentation and slides are available on the Arizona Telemedicine Program website, as well as her latest Virtual Office Hours event, where she answered billing and coding questions directly to billing administrators throughout the Southwest.


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About the Author

Mari Herreras serves as Communications Manager for Arizona Telemedicine Program and Southwest Telehealth Resource Center. She has worked in marketing and communications in publishing and nonprofits, as well as an award-winning journalism career for community and alternative newsweeklies in Tucson, Los Angeles, Seattle, and Wenatchee, Washington.