ABSTRACT
Introduction Coding, billing, and reimbursement compliance is a major issue for health care payment. While most of the publicity for improper payments is with the statutorily established payment systems such as the Medicare Physician Fee Schedule (MPFS), Ambulatory Payment Classifications (APCs), and Diagnosis Related Groups (DRGs), compliance is also an issue with healthcare payment from private third-party payers. The main difference is that for private third-party payers such as insurance carriers, the compliance issues revolve around contractual compliance. That is, whatever is in the contracts and associated companion manuals provides the framework for determining appropriate payment compliance within the contract itself. With the statutorily established payment systems, criminal prosecutions sometimes occur. With contractual compliance, litigation is generally over payments at the civil level.
