Sanctions for Billing Noncompliance

The Compliance Office manages a Provider Billing Audit Program, conducting chart reviews for each clinical provider. The objectives of these audits are to ensure that claims for services provided are coded properly, supported by adequate documentation, and that providers understand and follow all coding and documentation rules.

Clinical providers who are deemed not to be in compliance will be educated and, when necessary, disciplined. All audit failures will be reviewed by Compliance Leadership to determine any need to accelerate the sanction process below, e.g. moving from a Phase I audit failure immediately to Phase IV. If a clinical provider fails to cooperate in the education, reeducation, or any of the requirements listed below, the provider will be subject to immediate disciplinary actions such as fines, administrative suspension or Phase IV sanctions.

Should a physician fail a second audit (Phase II or beyond), the Department Chair/Chief is responsible for setting expectations and ensuring the failing physician resolves billing and/or documentation issues. If a physician fails a third or subsequent audit, the Department Chair/Chief will meet with the URMC Leadership Team to discuss the management of the failing physician.


Please review our Sanctions Policy for complete details.