What Is the Impact & Significance of Patient Payment Compliance?

Patient Payment Compliance

Are you facing increased payments due to high health plan deductibles and consumer-directed health care? Then you must ensure payment card compliance in order to avoid such issues.

Healthcare providers are increasingly challenged to maintain an efficient revenue cycle management that involves all the clinical and administrative functions that are necessary for the collection of patient service revenue. Once your RCM is streamlined you become able to achieve positive operating margins by boosting collections.

Significance Of Patient Payment Compliance

Patient non-compliance is a big problem in the United States. It is expected to cost even more in the future and currently costs billions of dollars annually. It is essential to figure out what is the reason for the difficulty and then resolve it with a proper solution. Moreover, healthcare costs are continually rising at a rapid pace across the industry. To receive on-time revenue it is integral to optimize the payment process from chart documentation to patient scheduling to clean claim submission to accurate payment posting.

On the other hand, if these procedures are not properly managed it can lead to increased errors in medical claims and improper steps to stay compliant. Your practice can face compliance risks if you submit claims hastily, seek improper payments from the insurance payers and compromise the patient’s privacy. Due to Illegal Medicare or Medicaid billing practices, healthcare providers face civil, administrative, and criminal penalties which can impact a medical practice from both financial and public relations perspectives. You can mitigate various of these downside organizational skills by implementing preventive measures. For instance;

  • Mandating organization-wide compliance training for all administrative staff/employed staff.
  • Admitting workflows that trigger mandatory compliance activities and implementing changes to the front office.
  • Utilizing accurate compliance management balance and checks processes.

In this blog, you will be able to understand the patient-focused compliance issues and compliance governance best practices to limit overall downside risk. Below are the mitigation strategies and potential negative outcomes of non-compliance issues that you must address on time;

Impact of Patient Payment Compliance

MSP Compliance

Description of IssueNon-Compliance RiskMitigate Strategies
For identifying any alternative payer priority status Medicare requires an MSP (Medicare Secondary Payer) questionnaire to give to patients when they need it.The risk of violating the provider agreement with Medicare arises when the healthcare providers consistently fail to identify alternative primary payers. They have to face criminal as well as civil penalties. They would be terminated from Medicare reimbursement.You must assure proper completion of the MSP questionnaire with Medicare coverage for patients. Build hard stops and make edits into the patient arrival processes and practice management system registration.

ABN Compliance

Description of IssueNon-Compliance RiskMitigate Strategies
For communicating with the patients about their health coverage, administrative staff and healthcare providers play a crucial role. In case of lack of medical necessity when providers believe Medicare will deny the payment. Medicare gives ABN ( the Advance Beneficiary Notice of Noncoverage) form to the patients in order to ensure proper collection of patient self-pay reimbursements.Providers risk losing the ability to bill patients for elective procedures if they do not comply with the ABN requirements.Conduct robust training with those staff and providers who handle pre-authorizations. Alert staff to Medicare patients who have no verified authorization for a particular service and incorporate appropriate workflows into the point of care operations and front-end office.

HIPAA Compliance

Description of IssueNon-Compliance RiskMitigate Strategies
HIPAA enables healthcare providers to document, transmit, and securely store confidential patients’ data. Medical facilities under the HIPAA privacy rule transmit health information electronically in connection with referral authorization requests, benefit eligibility inquiries, reimbursement claims, and protect such information from unauthorized access. Many providers choose to outsource operational functions to HIPAA-compliant billing service providers. They help you get familiar with the recent privacy rules and stay compliant with the HIPAA requirements and privacy rules.Healthcare providers are often subject to criminal prosecution/civil monetary penalties as they fail to comply with the other standards and HIPAA privacy rules. Persons who violate HIPAA privacy rules face imprisonment for up to one year and a fine of up to $49,000. CMPs can increase up to five years in prison and a fine of $99,000 when these offenses are committed under pretenses. The punishment is increased to imprisonment for up to 10 years and a fine of $249,000 when the individual intends to sell, use data for personal gain, commercial advantage, and malicious harm.It should be mandated that all healthcare organizations and their staff who are involved in handling the IIHI participate in refresher education sessions and take compliance training. They must ensure HIPAA compliance provisions are added and review new/existing partner contract agreements. Guarantee compliance with contract requirements by conducting appropriate site checks.


Inefficient care, pending patient payments, and improperly submitted claims can impact the financial performance of a healthcare business. Penalties from Medicare can be severe, if inappropriate admissions are found including termination of Medicare participation, CMPs, sanctions, etc. You must assure compliance staff is incorporating all key updates into decision-making workflows and actively monitoring changes to reimbursement guidelines/rules.

You must have appropriate ways to manage payment card breaches which is a serious threat nowadays. You must stay on top of compliance as patients frequently use debit and credit cards to pay for their healthcare payments. You can keep your patient’s data secure and safe. This helps you to mitigate the risk of a breach by ensuring your payment processing solutions are HIPAA compliant. Once you ensure you have diminished your risk of your patient’s financial data you will face no further complications related to your patient payment compliance. This will help you to safeguard your healthcare practice, build long-lasting trust with your patients while enhancing your business reputation.

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