Medical Billing, Healthcare Regulations

# How to Comply with Medical Billing Regulations Under the Affordable Care Act

- January 13, 2025
- Posted by Kristen Edwards

15 Nov

President Obama signed the Affordable Care Act as law to improve the US’s healthcare system in 2010. The Affordable Care Act is also known as Obamacare. Its main motive is to expand access to health insurance, improve the Medicaid service, reform the health delivery system, Control healthcare costs, and improve the quality of care given to the patients in the hospital. With the advent of time, business owners are transforming their organizations towards precision.

It is best for their consumers and their fame and reputation. In the same respect, the healthcare system also needed transformation as it is highly related to the nation’s health. Therefore, the government took this step to improve the people’s basic needs. The Affordable Care Act also stresses the improvement of the medical billing process. Medical billing has a huge impact on the financial patterns of people, and indirectly, it also affects the patient’s health.

This act set some standards for the healthcare institutes to proceed with the medical billing process. All healthcare institutes are now supposed to comply with the medical billing regulations to get the reimbursement on time.

This article will discuss the regulations forced by this act in the medical billing process and how healthcare and insurance companies should comply with these regulations.

## Understanding the Affordable Care Act

The Affordable Care Act was passed for three main reasons: expanding the Medicaid service, creating a fair health insurance marketplace, and introducing Essential Health Benefits (EHB). It was passed to improve the significant flaws in the healthcare system. Regarding the medical billing process regulations, the Affordable Care Act was passed to provide health insurance even to the country’s low-income families. It was to increase the health coverage under the insurance and to prevent surprise bills. All the medical billing regulations are introduced to make the community healthy.

## Medical Billing Regulations under the ACA

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### 1. Standardization of billing and coding

The International Classification of Disease, 10th edition (ICD-10) is introduced in this act. It greatly impacts the medical bills while assigning the codes for specific diseases. ICD-10 contains more specific and accurate codes for the diagnosis of diseases. The medical billers and coders must implement exact codes for disease diagnosis to claim services. In case of wrong implementation of codes, the claim can go into denial.

### 2. Preauthorization and Referral Requirement

Preauthorization is a control mechanism for providing only the necessary services to the patient. Previously, the provision of unnecessary services to the patients was reported several times, which caused stress on the patients’ medical bills. However, the Affordable Care Act has set standards for providing just required healthcare services. Otherwise, their reimbursement installment will be denied, and legal actions will be taken for violating the law.

### 3. Transparency in Pricing

In the past, hospitals provided unnecessary services to the patient, or patients got treatment from out-of-network physicians, which cost much more to the patient. But in this act, it is made mandatory for the healthcare administration or physicians to give complete knowledge of disease and its related services to the patients. It controls the cost of the healthcare services.

### 4. Essential Health Benefits

Regulations for the insurance companies regarding their insurance health facilities coverage are also described in the Affordable Care Act as medical billing regulations. Every insurance firm has to cover some healthcare benefits as a part of their insurance plan. There is no need now for the insurance firms to independently decide the number and extent of healthcare benefits for the patients.

## Compliance and Best Practices

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### ● Comprehensive Staff Training

There is a need to train the staff and make them adapt to the new medical billing regulations. There should be webinars and workshops to educate and train them. This helps in decreasing the ratio of errors in the medical billing process. Training the staff to use the medical codes correctly according to ICD-10 is recommended. To precisely complete the work, staff must also comply with preauthorization, pricing, and essential health benefits requirements. Training the staff is the foremost step to avoid the denials of claims.

### ● Robust Documentation

The proper patient and payer information is very important to complete the medical billing process on time. This needs to maintain the documents in which every information about the patient’s illness, treatment, medical services, personal information, and insurance information should be noted. This information will be needed when making a medical bill or in case of any objection from the insurance companies. Nowadays, electronic health records have replaced extensive documents in which information remains saved for a long time and can be reached anytime.

### ● Billing and Coding Audits

It is always recommended to do the audits after a specific time to detect and rectify the mistakes in the medical bills. This step helps the healthcare institute to avoid financial losses. Any case of over-billing to any patient can also be detected while doing the audits, enhancing compliance with the Affordable Care Act. This act aims to avoid the financial losses of the patients, and audits can help to identify any errors if present.

### ● Privacy Regulations

Medical billing regulations also include privacy regulations for the privacy and confidentiality of the patient’s information. Healthcare institutes should take immediate measures to improve patient data privacy to comply with the Affordable Care Act. Any breach in the privacy policy can be directly reported to the higher authorities, and it will be dealt with legally. In the large number of such breaches, there is a chance of a temporary ban on the healthcare organization. Therefore, healthcare institutes should take some steps to avoid any violations.

### ● Collaboration with Payers

The Affordable Care Act focuses on the financial stability of the patients, which can happen because of the financial stability of healthcare institutes and insurance companies. Therefore, it is necessary to maintain effective communication with the insurance firms to solve all the objections and denials on time.

### ● Telemedicine and Remote Billing

Telemedicine is an emerging field in which patients consult with remote physicians and get the prescription for their treatment. However, there is a debate about the medical billing of these services. The Affordable Care Act has some policies for telemedicine billing. Physicians should be aware of these policies to comply with medical billing regulations. Physicians should be aware of the medical codes related to different diagnoses of diseases and codes for remote consultations. Physicians should also learn virtual documentation techniques to keep records for reimbursement claims. Physicians, by themselves, understand the coding and reimbursement rules for telehealth services to claim successfully for the services rendered.

## Conclusion

The Affordable Care Act was passed as law by the government to correct all the existing flaws in the healthcare system. Its main objective is to improve the healthcare facilities, increase the insurance benefits coverage, and make poor patients financially stable for treatment. Some medical billing regulations are introduced in the act, like ICT-10, which makes the coding system more effective and transparent.

There is stress on the transparency in the pricing, preauthorization from the patient while starting the treatment, and provision of essential health benefits. These steps are taken to provide the best possible care to the patients. Medical billing regulations also include terms and conditions for telemedicine billing and its importance. Healthcare organizations and insurers must comply with these regulations to get the reimbursement timely by training the staff according to new policies, doing the billing and coding audits, and maintaining privacy standards. Healthcare organizations also communicate with the insurers to resolve their issues to make the medical billing process fast and smooth.

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