Billing compliance services
Practical compliance support for medical practices: the billing rules that apply to you, checked regularly and documented before anyone asks.
Billing compliance problems rarely start with bad intent. They start with a modifier used out of habit, an overpayment nobody refunded, a staff member who was never checked against the OIG exclusion list, or a payer policy that changed without anyone noticing. Each one can turn into a recoupment, a payer audit or a much larger problem.
SFA Solutions helps practices keep billing on the right side of the rules. We run billing and coding compliance reviews on a sample of claims each quarter, help you keep HIPAA policies and staff training current for billing work, and send updates when CMS, OIG or major payers change rules that affect your codes. We help you track and return identified overpayments within the required timeframe, check staff and providers against the OIG exclusion list, and keep documentation organized for audits. When a payer audit letter or records request arrives, we help you prepare the response and meet the deadline. We are not a law firm, so we point you to healthcare counsel when a question needs legal advice.
Who this is for
Compliance support suits practices without a dedicated compliance officer, practices that bill Medicare and Medicaid heavily, groups that have received a payer audit or records request, and specialties under frequent review such as behavioral health, physical therapy, cardiology and pain management.
Related services
What our billing compliance service covers
HIPAA policies and training
Help reviewing the HIPAA policies that apply to your billing work, plus staff training support, with gaps listed in writing.
CMS and OIG alerts
Plain-language notices when Medicare rules, NCCI edits, LCDs or OIG guidance change in ways that affect your practice.
Internal claim reviews
Periodic samples of claims checked against documentation, coding rules and payer policy, with findings and corrections.
Payer rule tracking
Commercial payer policy updates for your top codes, including modifier, authorization and coverage changes.
Overpayment and exclusion checks
Credit balance review, refund tracking, and monthly OIG LEIE checks for providers and staff.
Audit preparation and response
Help organizing records, writing responses and meeting deadlines for payer audits and records requests.
How we deliver it
Baseline review
We review your current billing and coding practices, HIPAA policies, refund handling and exclusion screening, and list the gaps.
Written plan
You get a short list of fixes in priority order, with owners and target dates.
Quarterly
We sample claims for coding and documentation accuracy and report findings with any corrections needed.
As needed
Rule change alerts go out when they apply, and we help with any audit letter or records request you receive.
Billing compliance rules practices should know
| Area | Requirement | Source |
|---|---|---|
| Medicare and Medicaid overpayments | Report and return within 60 days of identification; CMS allows up to 180 days for a timely, good-faith investigation | Social Security Act 1128J(d) and CMS rules effective 2025 |
| HIPAA breach notification | Notify affected individuals without unreasonable delay and no later than 60 days after discovery | HIPAA Breach Notification Rule |
| Exclusion screening | Do not bill federal programs for services by excluded individuals; check the OIG LEIE regularly | OIG exclusion authorities |
| Compliance program | OIG describes seven elements, from written policies to auditing and corrective action | OIG General Compliance Program Guidance (2023) |
| Coding edits | Follow NCCI procedure-to-procedure and MUE edits, updated quarterly | CMS National Correct Coding Initiative |
| HIPAA documentation | Keep required HIPAA policies and records for 6 years | HIPAA Privacy and Security Rules |
Billing Compliance for your specialty
We bill for 28+ specialties. These are the ones we work with most.
Nurse Practitioner billing
Billing for NP-led and physician-NP practices, from the 85% Medicare rate and incident-to rules to split/shared visits and getting each NP credentialed under the right NPI.
Learn moreInternal Medicine billing
Billing for internists who manage complex, chronic patients, with E/M levels, wellness visits and care management codes captured when the documentation supports them.
Learn moreOphthalmology billing
Eye exam codes, refraction, diagnostic testing, cataract globals and high-cost injectable drugs all follow their own rules. Ophthalmology is one of the specialties we bill most often.
Learn moreQuestions about billing compliance
What should we do if we find we were overpaid?
Medicare and Medicaid overpayments must be reported and returned within 60 days after they are identified. Since 2025, CMS allows that clock to be suspended for up to 180 days while you conduct a timely, good-faith investigation. We help you document the investigation, calculate the amount and process the refund. Commercial payer refunds follow your contract.
How often should we check the OIG exclusion list?
OIG does not set one required frequency for all providers, but monthly screening is widely recommended and is required by some state Medicaid programs. Billing for services by an excluded person can lead to civil monetary penalties.
Does every practice need a compliance program?
OIG's General Compliance Program Guidance encourages every provider to have one sized to the practice. For a small office, that can be a written policy set, a designated compliance contact, training, periodic claim reviews and a clear process for fixing problems.
Can you represent us in an audit?
We help you prepare records, write the response and meet deadlines. We are a billing company, not a law firm, so for legal questions or investigations we recommend working with healthcare counsel.
How do we hear about rule changes?
We send short alerts when a change affects your codes or payers, such as a new LCD, an NCCI update or a commercial policy change, along with what it means for your claims.
Start with a free review
Tell us a little about your practice. We will look at where billing compliance is costing you money today and walk you through what we find.
- No commitment
- Reply from an RCM specialist, typically within one business day
- No patient records needed to start
Get a free review
An RCM specialist typically replies within one business day.