As a third-party medical and dental billing company, it’s vitally important for Prospa Billing to understand HIPAA policies and procedures and how to apply them to our daily operations.

We understand the responsibility we bear to keep your patient data safe and secure and to conduct our services in an ethical and lawful manner. That’s why we have our own internal compliance program and standards of conduct that all of our professionals must follow.

Our top priority is to comply with all applicable Federal and State standards (Medicare, Medicaid, etc.), as well as the requirements of private health insurance companies.

All of our coders and billers are HIPAA-compliant and receive continuous training and education regarding updates in HIPAA policies and procedures, as well as our own internal standards of conduct.

Specifically, Prospa Billing strictly adheres to the Office of Inspector General’s (OIG) “Compliance Program Guidance for Third-Party Medical Billing Companies” to combat health care fraud and abuse, with a focus on 17 risk areas identified by OIG:

  • Billing for items or services that have not been actually documented
  • Unbundling
  • Upcoding (e.g., billing for a higher level of visit code when a lower level has been performed)
  • Inappropriate balance billing
  • Inadequate resolution of overpayments
  • Lack of integrity in computer systems
  • Computer software programs that encourage billing personnel to enter data in the fields indicating services were rendered that were not actually performed or documented
  • Failure to maintain the confidentiality of information/records
  • Knowing the misuse of provider identification numbers, which result in improper billings
  • Outpatient services rendered in connection with inpatient stays
  • Duplicate billing aimed at receiving duplicate payment
  • Billing for discharge in lieu of transfer
  • Failure to properly use modifiers
  • Billing company incentives that are in violation of the anti-kickback statute or other similar federal or state statute or regulation
  • Joint venture
  • Routine waiver of copayments and billing third-party insure only
  • Discounts and professional courtesy

To avoid these risks, Prospa Billing takes meticulous steps to:

  • Obtain proper and timely documentation of all physician services prior to billing to ensure that only accurate and properly documented services are billed
  • Ensure that claims are submitted only when appropriate documentation supports the claim and only when such documentation is maintained, appropriately organized in legible form, and available for audit and review
  • Confirm that the diagnosis and procedures reported on the reimbursement claim are based on the medical record and other documentation, and that the documentation necessary for accurate code assignment is available to coding staff at the time of coding
  • Provide that the compensation for billing department coders and billing consultants should not provide any financial incentive to improperly upcode claims
  • Establish and maintain a process for pre- and post-submission review of claims to ensure claims submitted for reimbursement accurately represent service provided, are supported by sufficient documentation, and conform with any applicable coverage criteria for reimbursement
  • Obtain clarification from the provider when documentation is confusing or lacking adequate justification


    To avoid these risks, Prospa Billing takes meticulous steps to:

    Keep patient data at the practice server. No patient data is migrated to another system.

If you have any questions regarding Prospa Billing’s compliance policy or practices, call us at (844) 663-3686.