Friday, December 20, 2013

White House broadens Obamacare exemptions

White House broadens Obamacare exemptions

Tuesday, December 10, 2013

How to Start Your Own Medical Billing Service, a Great Stocking Stuffer For the Entrepreneur in Your Family! On Sale! $19.99!

This would be an excellent stocking stuffer for that family member looking to start their own business. Or even for a stay at home Mom or Dad!

Comment on this post with your email address and I will invoice you directly for the low, low price of $19.99 (Ca sales tax will be applied for all California state purchases)!  Regular price $34.99.

This offer is available for the rest of the month of December 2013! Order yours today!

Monday, December 9, 2013

Keeping Up with the Copay: Health Plan Changes Always Happen

By Melissa Young, MD from Physicians Practice

I’ll be the first to admit: I don’t know all the details of my own medical insurance plan. And I’m the one who chose it! I reviewed the benefits at the time. I looked at what the copays would be for office visits and meds, and I looked at what the out-of-network benefits would be. Thankfully, I have not really needed to use it much, so I have forgotten much of the details.

Many of my patients are no better. I doesn’t help that their employers change their plans from year to year. And even if they keep the same plan, the insurance companies change their formularies and their benefits all the time. It often comes as a complete surprise to patients.

For example, I have one patient for whom I prescribed a medication earlier this year. The cost to her at the time was minimal; her prescription plan paid for most of it. She is due for it again now, but now she has this big deductible and it is going to cost her hundreds of dollars. I also have a patient whose ultrasounds I used to do in the office …until her plan decided they didn’t cover it if it was done here, so now she has to get it done in radiology. Of course, neither of us knew that before the last ultrasound I did here. Drugs that didn’t need prior authorization six months ago need it now.

I am certain patients are informed one way or the other about changes in their copay (although many of them seem surprised when my staff asks them for $40 instead of $25 like they paid last time), and maybe they get notice about other changes, but I would not be surprised if they give any mail they get from their insurance company a quick glance and then toss it. I can’t say I blame them. We all get so much mail that looks like junk; it can be hard to figure out which ones are really important. And since things change from month to month, who can keep track of it all?

Courtesy of Physicians Practice:

Is Your Billing Company Registered for HBMA's Free Professional Billing Service Locator Service?

Physician owners and medical practice administrators are already signing up and may be looking for you! Today, the HBMA unveiled the free, fully automated Professional Billing Service Locator (PBSL) service, a platform that provides an efficient way for physician owners and medical practice administrators to easily find a trusted, professional medical billing partner. HBMA developed the offering to help providers with the arduous task of navigating through the thousands of medical billing companies on the market to find a the HBMA member organization that will best meet their specific needs. After registration, the PBSL will immediately identify the specialties, service details, and contact information of the most relevant and qualified medical billing companies in the region that fit a medical practice's specific profile. Finding that perfect match with the right professional billing service will help providers secure appropriate reimbursement for services delivered, achieve timely claims adjudication, and reduce claims denials to lessen days in accounts receivable. To learn more about how to register your billing company into the PBSL directory, visit Professional Billing Service Locator or call 877.640.4262.

2014 Medicare Physicians Fee Schedule (MPFS) Available Soon

2014 MPFS Available Soon Watch for the 2014 Medicare Physician Fee Schedule (MPFS). It will be published on the “Fee Schedules” webpage at after its regulation is put on display.
Last Updated Nov 27, 2013

Health Insurance Exchanges: Two Key Issues to Discuss with Patients

The American Academy of Family Physicians (AAFP) is encouraging its members to provide their patients with information regarding health insurance exchanges.

The AAFP website advises: "During patient visits, be prepared to discuss the insurance options available through the marketplaces and encourage patients to make coverage decisions that are appropriate for their health care needs. "But not all doctors are ready to get involved.

The majority of physician respondents to a recent Medscape survey said that they should either have a limited role or no role in providing health insurance and health insurance exchange information to patients.

Yet, spending a few minutes sharing some key information about health insurance exchanges with interested patients may benefit you and your practice in the long run.

Here's why: If your patients that are shopping on the health insurance exchanges don't make well-informed purchasing decisions, you may see them less frequently. In fact, you may not see them at all.

Many of the health plans offered in the exchanges appear to have narrower networks — meaning patients will likely have fewer physicians and health systems to choose from within the plans.

In addition, many of the health plans offered in the exchanges have higher deductibles — meaning patients may end up shouldering more of their healthcare costs.

"They are trying to funnel people into narrow networks overall, and simultaneously shift people into higher cost sharing that is higher deductible, higher copay kind of plans," Kip Piper, a healthcare consultant in Washington, D.C., recently told Physicians Practice.

If patients purchase those higher cost sharing plans, it's likely that they will put off or avoid visiting your practice due to cost concerns, said Piper. In addition, higher patient cost sharing will place more burdens on your collections staff, as they will need to step up patient payment collection efforts
For that reason, you might want to consider talking to your patients about the importance of finding a plan that does not require a lot of out of pocket costs. "Make sure that ... they're not enticed by a low premium to pick a plan that has a high cost sharing that then keeps them out of the doctor's office," said Piper.

The narrower networks offered by many of the plans may also pose problems for your practice.

If you are excluded from a plan or if you have decided to opt-out of a plan, you run the risk of losing your patients to providers who are participating in that plan. For that reason, you might want to share which plans you are participating in with patients.

"I'm afraid of a lot of people in January are going to start making an appointment and then they're going to find out they can't go to their doctor," said Piper.

Article By Aubrey Westgate from Physicians Practice

Presentations to Physicians: Don't just Share Data, Provide Direction

Knowledge is power when it directs action. When someone is presenting a case or clinical research to a physician, both the presenter and the physician understand how the information can help the physician successfully address similar clinical circumstances in the future.

The purpose is the same in presentations of non-clinical information, but the implicit call for physician action is neither universally recognized nor understood. As a consequence, physicians are often left feeling helpless in the face of what is clearly bad news.

Consider some information recently shared during a Grand Rounds presentation to a group of orthopedic surgeons:

• In 2011, healthcare spending in the U.S. amounted to almost 19 percent of GDP. The inescapable conclusion is that we have reached the limit of funds available for healthcare, if we have not surpassed it.  Physicians cannot rely upon new money coming into the healthcare system

• The payment system is opaque, particularly to patients. Most hospitals in a recent survey were either unable or unwilling to hazard even an estimate of the costs for a total hip replacement for a patient with no co morbidities. Other studies have shown that there is no relationship between hospital charges and what they actually get paid for services.  Patients surveyed thought physicians' Medicare reimbursement for the surgery was five times what it is, and the patients thought it ought to be about four times the current rate.

There is a mismatch between supply and demand. The population is aging, and the obesity epidemic puts unsustainable demands on lower extremity joints. Physicians are opting to limit their Medicare participation or retire early, rather than accept prospectively lower levels of reimbursement. Concurrent with a potential shortage of surgeons, hospitals have a lot of unused beds and are continuing to expand their physical plants.

• Physicians have not been effective in preserving their reimbursement rates. Reimbursement levels for hip surgery have declined by as much as 50 percent, in non-inflation adjusted dollars, in the last 30 years. At the same time, hospitals and implant manufacturers have seen their reimbursements more than double.

The very high volume of total hip replacements performed in the US makes the procedure an obvious target for cost containment and cost reduction.

A lot of knowledge was shared, but it did not indicate a clear path forward. What can and should a physician do with the information?

As in a clinical presentation, the answers were implicit. The difference is that they were not obvious to the audience:

• There will be winners. The current system is unsustainable; and disruptive, systemic change is inevitable. The imperative is either to be one of the people who figures out how to thrive in the new environment, or to align with them.

• Patients are on their doctors' sides. Physicians can leverage that by being more transparent about the reimbursement levels and the problems they present. To be effective, this requires talking actual dollars. "The reimbursements don't cover my costs," sounds like sour grapes. Patients can be moved to contact their representatives in support of physicians, especially if their access to care is a potential casualty of the status quo.

• Given that the pie is not growing, physicians need to get a bigger piece of it. This may be the best news about bundled reimbursements. Hospitals and device manufacturers have done a good job of maintaining healthy margins. Physicians should be able to argue for and achieve a more appropriate piece of the total cost of a procedure for two reasons:

1. The physicians are the ones who are doing the actual work that drives all hospital and implant revenue.
2. Patients tend to choose physicians, as opposed to hospitals or specific devices.
The redistribution will not happen automatically. If physicians are not aggressive and effective in advocating for themselves in the allocation of bundled payments, they will encounter a reprise of the Medicare fee-for-service situation.

The critical question for any presenter is "What do you want me to do with that information?"  Each presenter has a duty to provide the answer, either in the course of the presentation or in response to audience questions,

Article By Carol Stryker from Physicians Practice

Maximizing Physician Compensation at Your Medical Practice

The financial pressure is on for physicians to get compensated not just fairly, but well, at their practices, and Shawn Harkey's medical group is no different.

"We definitely keep a close eye on both fixed and variable components," says Harkey, the financial services director of Texas Retina, an ophthalmology practice with 13 locations in the Dallas-Fort Worth area. "Medicare payments aren't necessarily increasing and we're fighting that battle because the high majority of our patients are over [the age of] 60. That's forcing us to become leaner, more efficient in providing patient care.

" Harkey's practice, which has been using its NextGen EHR for six years and its accompanying practice management system for three years, has already seen improved efficiency (physicians can see patients in a more timely manner) and a reduction in overhead costs, such as paper, storage, and staff time spent manually pulling charts.

Today, the practice is also using its Navicure claims clearinghouse technology to verify patient insurance in advance of appointments to avoid a cash-flow slowdown.

"We see a high volume of patients every day so we make sure we have everything checked, such as benefits and referrals, and we use a number of high-cost drugs so we can make sure there's no issues in place with payers," says Harkey.  The state of physician pay is not only changing, but it is also challenging, as Harkey and our annual Physician Compensation Survey respondents would attest. But by taking a proactive approach — taking stock of the trends and seeking new ways to maximize compensation — physicians can not only stay alive, but they can also thrive, financially.

 * (To see the data, check out the details of our 2013 Physicians Compensation Survey here.)

The state of physician compensation

Today's physicians are under increasing pressure to make money and see more patients.

While more than two-thirds of the 1,474 physicians who answered our survey told us their income is, to some degree or entirely, tied to productivity, just one-third of physicians said their income is tied, at least in part, to value-based metrics. Twenty-four percent of physicians told us their income relies in part on patient satisfaction.

"[Value-based reimbursement] is growing at a small level, and the reason is that there is not funding available for it," says Kenneth Hertz, a Medical Group Management Association healthcare consultant. "If you're earning $250,000 per year and your practice wants to put in place this value-based reimbursement, quality metrics, and other performance metrics, the practice will need to secure additional funds to pay you. Right now, the payers are not providing additional significant dollars to do this. In most cases, practices are having to carve out a pool of money from the current funds available to pay physicians, and then pay those that meet the quality metrics out of that pool."
Regardless of the basis of their payment, more than half of docs in this year's survey — 53 percent — said they were either "slightly" or "highly" disappointed with their income.

"I think there are financial pressures [such as] the changing payment models, the increase in expenses, the reduction in reimbursement in practices," says Hertz. "If you're in private practice you're seeing your expenses go up, and you're seeing reimbursements go down."
Today, many specialists are making more while primary-care physicians are staying flat, income-wise, adds Tommy Bohannon, divisional vice president of recruiting at Merritt Hawkins, a physician staffing agency.

Article By Marisa Torrieri Courtesy of:

You Need to Adapt in Order to Survive: How Your Medical Billing Service Can Prosper During the Healthcare Industry Chaos

How Your Company Can Prosper During the
Healthcare Industry Chaos

The healthcare industry is facing a state of complete disorder and confusion: Uncertainty surrounding the implementation of the Affordable Care Act, the looming switch to ICD-10, EHR and "meaningful use" deadlines, hospital acquisitions of physician practices, new HIPAA rules, and Health Insurance Exchanges... the list goes on. It seems like a challenging time for medical billing companies – and it is.
The good news is that not only can you prosper, you can bring hope and financial stability to struggling practices and salvage some that would otherwise collapse and shut down (or get swallowed up by a hospital or other acquisition entity). How can you assure your and your clients' continued prosperity and growth?
Focus on becoming a full-service revenue cycle management company.
In today's dynamic marketplace, billing companies that do not keep up with the constant changes will be left in the dust by companies that do. You must not only stay current with what is happening in the industry, you need to make alliances with other companies that can provide services to your clients that will help them solve cash-flow challenges beyond just their medical billing. The more services you can offer to your clients, the more you will be perceived as "the expert" who can solve their cash flow problems.

A brief review of the latest issue of Billing will introduce you to vendors that can be valuable to you in assisting your clients with medical coding questions, HIPAA compliance, EHR Meaningful Use attestation, online document management, patient portals, integrated payment channels, patient collections, and other revenue cycle issues. Do not forget that HBMA conferences will introduce you to technology partners that can help you keep up with changes in this dynamic industry.
Make sure you are using a billing system that is fully integrated with an EHR system.
Many outdated, server-based billing systems are trying to patch together a practice management system with one of the new electronic health record systems designed by a different company or on a different platform. The company that developed the practice management (PM) system creates an interface with an EHR system developed by another company. Chaos generally ensues.

If this is the case with your PM system, you are only asking for headaches and a possible loss of clientele. EHR companies are dropping by the wayside every day. Some of them are also server-based. Trying to get them to work together with billing software is like using "bubble gum and bailing wire" and will only lead to ongoing issues in your company. Two different companies, with two groups of programmers, trying to keep all the different parts of both systems running smoothly is almost impossible and can lead to turmoil in your company.

As painful as it may seem now, it may be a good idea to begin looking for a billing system that is totally integrated with an EHR system. That means that it was designed from the ground up by the same programmers in the same company. There are such systems available, and most of them are cloud-based (accessed securely 24/7 through a browser via the Internet).

Anything less than total integration of the two systems could be a disaster waiting to happen. Start your research now and find a system that will take you into the future, especially with any new clients you bring on. And, as part of your due diligence, make sure there is a way to import the data from your current system into the new system (at least the patient demographics). Then, begin to educate your current clients on why they need to start using an EHR, if they are not already, and why they might need to use a system that is fully integrated with your billing system.

Look for a system that has a way to electronically communicate with insurance company databases. You need one that checks for eligibility and automatically imports the patient data directly from the insurance company's database to create new patient charts. This will save you hours of data input and will help you keep employee costs under control. It will also prevent you from submitting claims that are sure to be rejected because the patient was not eligible for the service and it will keep the practice from spending time seeing patients that insurances will not cover. This will increase your revenue for that practice and will eliminate a large number of claim rejections as well.
Keep up with changes in the industry.
I can predict the success you are going to have in your business – and in life in general – if you will tell me just two things: the people you associate with and the books (and periodicals) that you read. Do not get bogged down in the details of your billing business. You need to set aside time to attend industry conferences at least once a year and to read industry newsletters and books.

The person who does not read is no better off than the person who cannot read, so set aside time each week to read about our industry and keep up with the constant changes. Change is what life itself is based on, and if you are willing to change along with the industry, you and your clients will prosper.

Do not assume you will have your current clients forever.
You won't. Things change in medical practices: staff turnover, new policies and procedures, new government rules and regulations, competition, updated technology, and the marketplace itself. All these things can cause you to lose a client from time to time. You must always be marketing.

Whether you realize it or not, your competition in this industry is not just other medical billing companies. The practice itself is your biggest competition. All it would take is for a new office manager to come into one of your practices and decide that they would rather not outsource their billing: they think they can do it themselves more efficiently and more economically. You must keep reselling your clients on your efficiencies and on your cost savings versus doing the billing themselves internally. Provide them with revenue reports that delineate what percentage of billed dollars (expected) are actually being collected. Show them you are the expert in this industry by producing and providing to them a professional newsletter with articles that show that you keep up with the changes in the industry. HBMA has a newsletter you can purchase and tailor with your company logo ( 

Take the practice administrator (or the doctor) to lunch from time to time and show them printed reports that illustrate the revenue collections from both insurance providers and patients. Hold "Lunch 'n Learns" on a regular basis with your clients to bring them up to date on what is happening in the medical industry. Position yourself as the expert. People want to do business with "the expert" in every field.

When you buy a home, you do not want the new real estate agent: you want the guy or gal who has sold 100+ homes. When you look for a CPA, you do not want one who just hung out his or her shingle: you search for one who pays less than double digits of their own taxes and has a number of clients who they service. The same is true of a doctor's office. They want to feel that they are dealing with the company that can bring in every last dime that is due to the practice.

Continue to network with other business people in the community and join your local BNI group or chamber of commerce. Get out once a week and let people know you can solve the cash crunch for doctors and help them build their practices through your contacts.

Set up an automated way of keeping in touch with everyone you come in contact with who is a prospective client. Let them know that you are the only company that they should do business with. When it comes time for them to decide to outsource their billing, you are the only choice that makes sense. People do not buy when you are ready to sell – they buy when they are feeling the pain. Be at the top of their list when they decide it is time for change.

Remind your current doctors and office administrators that you are looking to build your business. Assuming you have done a good job for them, ask them for a referral. You would be surprised as to how many billing company owners never ask their clients for referrals. Do not just ask for the name of someone. Ask your client to pick up the phone and call the other doctor or office administrator and tell them how pleased they are with your billing service and that they think it would be in their interest to meet with you.

You can shrivel up and die in this ever-changing industry, or you can make the choice to grow and prosper, starting right now!

Everest College Announces Partnership with HBMA

Everest College, a provider of career-oriented diploma and degree programs at more than 100 campuses across the nation, recently announced an alliance with the most influential healthcare revenue cycle and management services association, HBMA ( Under the agreement, HBMA will provide externship and placement opportunities within its large membership base for Everest's Medical Insurance, Billing, and Coding (MIBC) students and assist in the development of the school's MIBC curriculum.
"HBMA will help us enhance our MIBC program for our students. In turn, we'll be able to provide more well-trained, highly qualified students and graduates to work with HBMA member companies," said Anthony Mann, director of national employer development for Everest College. "For instance, Everest's externship, or '200 hour interview' as it is commonly referred to as, provides an in-depth opportunity for an employer to see a potential employee in their work environment. This opportunity opens doors to new externship and – and ultimately job opportunities – for our students and graduates."

"Currently, we are working on a website presence that will enable Everest students to view externship and placement opportunities, and to enable our membership base to view the credentials of Everest students. We are confident that our alliance with Everest will be fruitful in helping more graduates find employment, as well as provide our members with quality recruits," stated HBMA Director of Operations Sherri Dumford.

Barbara Lewis, director of talent management with HBMA member organization AdvantEdge Healthcare Solutions, shared that her organization has participated in Everest's externship program for a number of years and states, "Everest provides us with a qualified candidate pool that we can turn to when there is an immediate need for talent. These trained students and graduates are vested in our industry and are motivated to learn and do well."

If you are interested in finding out more about how your organization can participate in this program, contact Anthony Mann at or (714) 913-7251 or Sherri Dumford at or (877) 640-4262, ext. 201.

Courtesy of:

Improve Clinical Documentation for ICD-10

By Rhonda Buckholtz, CPC, CPMA from Physicians Practice

With less than a year left before the "go-live" date for ICD-10, industry focus is turning more and more to clinical documentation improvement (CDI), as it will be even more vital to every facility. -

Under ICD-10’s more rigorous specificity requirements, physician documentation will need to meet the higher standard as well. If your practice is fully prepared for ICD-10 in every other aspect, but clinical documentation has not improved, accurate coding and proper payment will not be possible.

A recent study of more than 20,000 audits of physicians’ clinical documentation revealed that only 63 percent of current documentation is sufficient for ICD-10’s specificity levels. Keep in mind, the insufficient documentation found in these audits often represented a larger percentage of at-risk revenue. For example, in one larger assessment, findings indicated seven of the most commonly used diagnosis codes accounted for 93 percent of the facility’s revenue.

Here are a few examples of where documentation changes will likely be needed:

Diabetes documentation must include:
• Type of diabetes
• Body system affected
• Complication or manifestation
• If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required

Neoplasms documentation must include:
•Type:Malignant (Primary, Secondary, Ca in situ)
Unspecified behavior
• Location(s) (site specific)
• If malignant, any secondary sites should also be determined
• Laterality, in some cases

Asthma documentation must include:
• Severity of disease:
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
• Acute exacerbation
• Status asthmaticus
• Other types (exercise induced, cough variant, other)

These are only a few examples of the more specific documentation requirements.

To avoid an increase in denied claims under ICD-10, perform an ICD-10 readiness assessment. Here's how:

Start by running a report in your computer system and sorting it by diagnosis code. Next, take your top 10 most commonly used diagnoses and run another report of patients that had those diagnoses appended to them. Pull 10 to 20 charts for your most commonly used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis only. Look at the history and the assessment, and see how much can be coded under ICD-10-CM.

Based on the documentation, determine how many of these notes:
• Could be coded under ICD-10-CM
• Need more specific information to code
• Had to be coded to an unspecified code

Each provider in your facility should review these findings so they understand what documentation is needed to support this specific diagnosis in ICD-10. Then, move on to the next diagnosis on your top 10 list, and keep evaluating until your list is complete.

The facility should have a target percentage for the assessments and schedule future readiness evaluations, even if the goal is reached along the way.

How often these evaluations take place will depend on the number of providers at your facility, the number of different specialties, the type of specialties (some are seeing more changes in ICD-10 than others), and how providers perform. To ensure a smooth transition and a minimal impact on revenue, these assessments should become part of the regular audit process even after implementation of ICD-10. 

Courtesy of: Physicians Practice

Friday, November 22, 2013

Physicians Dropped by Health Plans for Overutilization

By Averel B. Snyder, MD from Physicians Practice

After United Healthcare dropped 15 percent of its provider panel, I was not surprised. I actually thought something like that would occur sooner. It is clear that for Medicare to survive and to decrease healthcare costs in this country, healthcare delivery needs to change. Most believe that fee-for-service reimbursement is no longer an option and there seems to be a shift toward pay for performance. Clearly, increasing quality, decreasing costs, and increasing patient satisfaction are goals both payer and provider would strive for.

There are certain services in place to help meet these goals. One such example is the Medicare Annual Wellness Visit (AWV). The AWV, by delivering evidence-based preventive services, helps keep patients healthier and prevents over-utilization of services. The visit also helps satisfy quality measures for PQRS reporting. Despite all these advantages only approximately 12 percent of Medicare beneficiaries have had their AWV.

Another way to increase quality and decrease costs is to identify those patients that are at increased risk of overutilization. The current methodology to identify risk is the CMS HCC method. In addition to identifying risk by assigning a risk score to each patient, the codes are necessary for Medicare Advantage (MA) plans to get paid from CMS. The majority of physicians do an incomplete job of coding, making it necessary for MA plans to use third-party providers for risk assessments and retrospective chart reviews. There are now automated software solutions that provide all the components of the AWV and calculate the CMS HCC risk score real time.

The point is that fee-for-service overutilization, no coding, and not providing quality measures will not be and should not be tolerated. Those plans with strong executive leadership will identify those top 15 percent physician over-utilizers and not allow them to participate in the MA plan. If I was one of those executives I would make the same decision. It is time to make the paradigm shift and provide the highest quality care as cost efficiently as possible. It is to the providers' advantage to provide wellness visits for all their Medicare patients, and to understand the nuances of HCC coding.

Article By Averel B. Snyder, MD from Physicians Practice

Revenue Cycle Efficiencies and ICD-10

By Rachel V. Rose, JD, MBA from Physicians Practice

According to a Bank of America Merrill Lynch Executive Insight Report, Opportunities From Financial Efficiencies, produced in collaboration with HealthLeaders Media, financial leaders indicated that the "revenue cycle is where they could find the most efficiencies. The revenue cycle has been a focus of the industry for years, but the need for improvement is increasing given the payment model shifts that will come as a result of healthcare reform." (p. 2).

Given the upcoming October 1, 2014, transition to ICD-10, the revenue cycle is being scrutinized more closely than ever in preparation for the greatest impact on healthcare billing since the transition to prospective-payment, diagnosis-related groups (DRGs) in the early 1980s. Currently, physicians and other healthcare providers are considering how to contend with the decrease in claim-submission productivity due to the increased specificity, as well as potential denials and the effect on the revenue cycle.

Given the multiple aspects of ICD-10 transition, which could be focused on, I am going to provide some suggestions in the area of coding and compliance, which I have addressed directly with providers. First, like HIPAA, all entities are required to meet the ICD-10 requirements, regardless of their size. In light of this, coding and compliance policies and procedures should be established based upon state, federal and regulatory agency guidelines. Moreover, private payers may be implementing similar standards, especially those involved with Medicare Part C claims submissions.

For these private payers, state prompt-pay laws may be in effect that will enable providers to collect for untimely billing practices by private payers. Second, educating everyone throughout the revenue cycle proactively will enable efficiencies to be captured now and reduce the cash gap during the October 2014 transition. Third, regular compliance audits, including medical necessity, are critical to reducing adverse outcomes from RAC and ZPIC audits, as well as diverting the billing departments' efforts from clean claims submissions to reactively dealing with legal processes. Finally, the caliber of coders is crucial. It is inadvisable for providers to skimp on coder certification, training, and input. Outsourcing is also an option, but make sure that the appropriate HIPAA and Health Information Technology for Economic and Clinical Health, or HITECH, Act business associate requirements are in place.

In sum, "revenue cycle issues … caused the most anxiety among [the BAML] survey respondents, with 25 percent saying they felt 'very' exposed to potential losses." (Ibid. at p. 5). By being proactive and implementing effective compliance programs, healthcare providers can reduce their anxiety and potentially mitigate significant losses on the revenue cycle.

By Rachel V. Rose, JD, MBA from Physicians Practice

Medical Practices: Think Twice Before Waiving Copays

Historically, family practices and many other physicians groups have routinely waived insurance copays as a gesture of goodwill to patients in a tight economy. After all, who wants to hound sick patients for their portion of the charges?

There was a time when insurance companies turned a blind eye to these routine waivers of copays. Not anymore.

The AMA's Code of Medical Ethics Opinion 6.12 explains why routine waivers are unethical, particularly when a clinic advertises a willingness to waive copayments.

Further, the Office of Inspector General (OIG) has long taken the position that routine waiver of copayments constitutes an illegal kickback, which is a felony. 

The routine waiver of copayments also constitutes a violation of the terms of private insurance company plans. This contractual violation serves as a basis for a recoupment audit, during which insurance companies request proof of collection of copayments for five randomly selected patients. If the clinic cannot prove it collected, or at least exhausted all reasonable means of collection, then the carrier may demand a refund for any benefits paid across a large patient population.

Perhaps most frighteningly, routine copay waivers constitute ordinary financial fraud. If a patient is charged $100 and the insurance carrier is billed $80, the patient is supposed to pay $20. If you never attempt to collect the $20, this means the actual charge is $80, not $100.  Therefore, the insurance company should only pay $64 (80 percent of the $80
Fraud or dishonesty is a primary way to get in trouble with state medical boards.

There are provisions for waiving copayments in cases of financial hardship. At a minimum, you should document the financial hardship, and obtain a release from the patient to turn the financial document over to the insurance company, if requested.

The OIG states the following criteria for waiver on the basis of financial hardship:

• The waiver must be based on a good faith determination of the patient’s financial need. In other words, waivers must not be applied routinely. The government does not specify the financial status that would justify a waiver, so you should develop your own approach, apply it consistently, and document your efforts. For example, if your efforts to collect on a patient’s bill fail, or if it’s obvious that a patient is struggling to pay the amount owed, ask the beneficiary to fill out a form noting their employment status and average household income and expenses. Then make your determination based on the information provided.

• The waiver must not be based on the amount of the charges. Your decision about whether to waive what a patient owes should be based on the patient’s ability to pay without regard to what Medicare may have paid or the total charges for the service.

• The waiver must not be offered as part of an advertisement or solicitation.

State laws vary regarding waivers. Therefore, seek the advice of an experienced health lawyer in your state if you have questions about your practices.

Article By Martin Merritt from Physicians Practice

Physicians and the Financial Challenge of Providing an Interpreter

By Melissa Young, MD from Physicians Practice

I’ve written before about unexpected expenses, and we recently ran into another one.

Practices are required to provide access to care to patients regardless of their ability to speak the same language as the physician, and the practice must provide a reliable way to communicate with the patient. That means for patients who do not speak English (and in our practice, instead speak Filipino or Urdu), a translating service must be available.  Patients may decline and use a family member, but the service must be available. There are different options for such a service. If there is a staff member who speaks the same language as the patient, the staff member can do it. Or the practice can contract with a translator service. As a less-expensive alternative, there is software that can translate, although that doesn’t always work as well. There are also telephone-based translating services. Well, it isn't just the non-English speakers who need a translator. We recently had a patient come in who is hearing-impaired. When his appointment was confirmed, he reminded us (through a representative) that it is our responsibility to provide a sign-language interpreter.
We had never needed the services of a signer before.  Fortunately, he provided us with the number of someone we could call. It turns out, such services cost between $150-200 in our area. At least, that was the quote we got.

At $150-200 a visit, that pretty much means that, at best, we break even for the visit, and more likely, we lose money each time we see him. Since it is a requirement, I thought, "maybe there is a CPT code for 'use of a translator.'" Maybe we could get reimbursed for hiring someone. Alas, there is no such code, at least not that I could find.  Now, this patient legitimately needed to see an endocrinologist. He wasn’t one of those people who just think they have an endocrine disorder because they are tired. He needed to be seen, and he will need follow up. And every time he comes, he needs an interpreter. Unless (according to the regulation) there will not be a significant amount of communication involved. What kind of doctor visit doesn’t entail communication? My biller/husband said we should be able to say we can't see him, but (aside form it being the right thing to do) we have to, otherwise it violates a whole bunch of regulations. The exception to the rule is if it places "undue strain" on the practice. And according to previously filed lawsuits, one patient doesn’t break the bank. So, we will continue to see him and provide him with an interpreter and take a loss each time. I was curious to know what the experience has been in other practices.

Article from Physicians Practice By Melissa Young, MD

Pleasing Patients Best Marketing Strategy for Medical Practices

Making your medical practice easy to do business with will differentiate it from others, establish a competitive advantage, and make it highly appealing to patients. Here are some of the many ways that physicians can make it happen.

1. Create convenient hours

Many people have workloads or requirements that limit their availability for doctors' appointments during the traditional 9 a.m. to 5 p.m. work day. To accommodate this population, many physicians have office hours beginning at 6 a.m. or 6:30 a.m. to accommodate "early risers" on their way to work, or those coming off night. Others have evening hours ending at 8 p.m., 9 p.m., or 10 p.m. to accommodate commuters and others for whom daytime appointments are inconvenient or impossible.

There are also pediatric practices that are open from 5p.m. to 5a.m. The premise is that the need for healthcare services often occurs after doctors' offices are closed —necessitating a costly trip to the emergency room or a night of worry waiting until doctor's office reopens.

"Availability" for a target population that needs the convenience of extended hours, is a strategy that works.

2. Increase phone availability

Many practices have telephone access only from 9 a.m. to 5 p.m. and are "closed" for lunch. This makes no sense if early morning callers are working men and women who do not want, or are unable, to call from work. Others prefer not to have their coworkers overhear their medical problems (or birth date when asked for it) or may not have access to a phone at work. For similar reasons, some patients may prefer to call you during their lunch break or at the end of their workday after 5 p.m. New-patient callers (with any of the above restrictions) are not likely to call back.

Recommendation: Have an employee available to answer the phones approximately one hour before the office opens, one hour after it closes, and during the hour your office might be closed for lunch. The calls that you might otherwise miss (and the goodwill you'll generate by being available) will be worth it.

3. Use electronic health records

Utilize EHRs to reduce the need for patients to fill out the same forms at each office visit, provide electronic referrals allowing easier access to follow-up care with specialists, and have the convenience of e-prescriptions electronically sent to patients' pharmacies, among other benefits.

4. Establish a Web portal

Provide an easy-to-use Web portal so patients can schedule, reschedule, or if necessary, cancel appointments, and access and print health history forms that can be filled out prior to coming to the office. A portal will also allow your practice to view and update patients' contact, insurance, and other personal information. Patients can also make electronic payments, request prescription refills, receive test results, and exchange secure messages with doctors about lab-test results (eliminating telephone tag).

To make these interactions even more convenient, give patients the freedom to connect to your practice from their smartphones via a mobile app.

Recommendation: Make sure your website is HIPAA compliant and as secure as possible.

5. Provide Wi-Fi

Provide Wi-Fi, it's a nice extra. Patients can then use their smartphones, iPads, laptops, etc., while waiting. It doesn't eliminate the inconvenience of long waits but it does make them more tolerable.

The great jazz pianist and composer Fats Waller knew about being easy to do business with. He said, "Find out what people want, and how they want it, and then give it to them just that way." He was spot on.

Courtesy of Physician Practice By Bob Levoy, the author of seven books and hundreds of articles on human resource and practice management topics. His newest book is "222 Secrets of Hiring, Managing and Retaining Great Employees in Healthcare Practices" published by Jones & Bartlett. He can be reached at

Wednesday, November 20, 2013

Improve Your Patients’ Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Medicare Part B/Noridian

MLN Matters® Number: SE1338
Related Change Request (CR) #: NA

Related CR Release Date: NA
Related CR Transmittal #: NA
Effective Date: NA
Implementation Date: NA

Provider Types Affected

 All health care professionals who care for Medicare patients.

What You Need to Know

Medicare covers an annual preventive visit for all Medicare patients. These visits are:
  • The Initial Preventive Physical Examination (IPPE); and
  • The Annual Wellness Visit (AWV).
These examinations allow you to assess your patients' health on an annual basis to help you determine if they have any risk factors and if they are eligible for other preventive services and screenings that Medicare covers.

These examinations are a great way for you to detect illnesses in their earliest stages when treatment works best. The average reimbursement level for the AWV is about $107 and about $150 for the IPPE with no patient deductible or co-pay. These are cost-effective services as well as a good way to keep in touch with your patients every year.

Note: Please check the physician fee schedule for the exact amount of reimbursement for your locality and setting. You can view the physician fee schedule by visiting This link takes you to an external website.  on the Centers for Medicare & Medicaid Services (CMS) website.

The Initial Preventative Physical Exam IPPE (Welcome to Medicare physical)
Medicare covers an IPPE for all patients who have newly enrolled in Medicare Part B.
  • The patient must receive this service within the first 12 months after the effective date of their Medicare Part B coverage.
  • The IPPE is a one-time benefit.
  • There are 7 components in every IPPE:
    • Review the patient's medical and social history;
    • Review potential risk factors for depression and other mood disorders;
    • Review functional ability and level of safety;
    • An examination of the patient;
    • End-of-life planning;
    • Education, counseling and referral based on the previous 5 components; and
    • Education, counseling and referral for other preventive services.
For more information about the IPPE, including a more detailed description of the 7 elements, please see "Quick Reference Information: The ABCs of the IPPE" at This link takes you to an external website.  on the CMS website.

The AWV or Annual Wellness Visit

Medicare covers an annual AWV for patients:
  • Who are no longer within 12 months of the effective date of their first Part B coverage period; and
  • Who have not gotten either an IPPE or AWV within the previous 12 months.
Medicare pays for only one first AWV. Medicare will pay for a subsequent AWV for each patient annually. Note: The elements in first and subsequent AWVs, and the codes to bill them, are different.
  • There are 6 elements in a first AWV:
    • An assessment;
    • Establishment of a current list of provider and suppliers;
    • Detection of cognitive impairment the patient may have;
    • Establishment of a written screening schedule;
    • Establishment of a list of risk factors; and
    • Providing personalized health advice and referral to appropriate health education or other preventive services.
  • There are 8 elements in a subsequent AWV:
    • Update health risk assessment;
    • Update medical and family history;
    • Assessment;
    • Update of list of current providers and suppliers;
    • Detection of cognitive impairment the patient may have;
    • Update of the written screening schedule;
    • Update of the list of risk factors; and
    • Provision of personalized health advice and referral to appropriate health education or other preventive services.
As long as a physician is providing supervision, appropriately trained members of your office staff can provide the components of the AWV.
For more information about the AWV, including a more detailed description of the elements of the AWV, please see
Additional Information

The Medicare Learning Network® has published a variety of additional educational material on Medicare-covered Preventive Services, including:
For general information about Medicare-covered preventive services, visit the CMS Prevention page at This link takes you to an external website.  on the CMS website. For information to share with your Medicare patients, please visit This link takes you to an external website.  on the Internet.
Last Updated Nov 18, 2013

Update to Medicare Deductible, Coinsurance, and Premium Rates for 2014

MLN Matters® Number: MM8527
Related Change Request (CR) #: CR 8527
Related CR Release Date: November 15, 2013
Related CR Transmittal #: R82GI
Effective Date: January 1, 2014
Implementation Date: January 6, 2014

Provider Types AffectedThis MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, Regional Home Health Intermediaries (RHHIs), Durable Medical Equipment/ Medicare Administrative Contractors (DME/MACs) and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action NeededThis article is based on Change Request (CR) 8527 which details the new Calendar Year (CY) 2014 Medicare premium, coinsurance, and deductible amounts. Make sure that your billing staffs are aware of these changes.

BackgroundBeneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital. An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible. A beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during a spell of illness.
Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person's initial enrollment period, a 10 percent penalty is assessed for 2 years for every year they could have enrolled and failed to enroll in Part A.
Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When Part B enrollment takes place more than 12 months after a person's initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll.
The updated rates are as follows:


  • $1,216.00
  • $304.00 a day for 61st-90th day
  • $608.00 a day for 91st-150th day (lifetime reserve days)
  • $152.00 a day for 21st-100th day (Skilled Nursing Facility coinsurance)
Base Premium (BP)
  • $426.00 a month
BP with 10% surcharge
  • $468.60 a month
BP with 45% reduction
  • $234.00 a month (for those who have 30-39 quarters of coverage)
BP with 45% reduction and 10% surcharge
  • $257.40 a month

Standard Premium
  • $104.90 a month
  • $147.00 a year
Pro Rata Data Amount
  • $114.99 1st month
  • $32.01 2nd month
  • 20 percent
Additional InformationThe official instruction, CR 8527 issued to your MAC regarding this change may be viewed at This link takes you to an external website. on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at  This link takes you to an external website. on the CMS website.

Monday, November 18, 2013

A little known rule in the ACA could pose financial risk to doctors

A little known rule published by CMS to implement the Affordable Care Act (ACA) could pose a significant financial risk for doctors, hospitals and other healthcare providers. The rule requires health plans participating in the exchanges to provide individuals purchasing insurance through the exchanges a grace period before terminating the coverage for non payment of the premiums. Doctors and other healthcare providers will continue to provide care during the grace period, but the insurance plan will not be required to pay the claims incurred during most of the grace period. The result could be that physicians and other healthcare providers would provide a significant amount of uncompensated care.

Details of the rule

The CMS rule provides individuals that purchase subsidized coverage through the exchanges a 90-day grace period before their coverage is cancelled for non payment. The insurance plan is required to pay any claims incurred during the first 30 days of the grace period, but the insurance plan is not required to pay the claims incurred during the last 60 days of the grace period if the individual’s coverage is terminated. The insurance plan is allowed to place all the claims during the last 60 days of the grace period in a pending status. The rule requires the insurance plan to notify the healthcare providers when an insured individual is in the last 60 days of the grace period.

Risk falls on healthcare professionals and providers

The rule imposes a significant risk for uncompensated care on the healthcare providers. The rule does require insurers to tell healthcare providers when patients are behind on their premium payments, but he rule does not specify how the health plan will provide that notice to the providers. The only notice some providers receive will probably be the pending status placed on the unpaid claims by the insurance plan.
Many doctors and hospitals are reluctant to participate in insurance plans offered on the exchanges due to the increased financial risk associated with the CMS rule. The result could be that individuals enrolling in insurance plans through the exchanges may find it difficult to find a healthcare provider willing to accept them as patients. CMS has been asked to modify the rule so that insurers are required to pay claims during the entire 90-day grace period.

How grace period can be manipulated to benefit patients

The CMS rule may also result in individuals manipulating the system. Some individuals may intentionally pay premiums for only part of the year and become serial abusers of the 90 day grace period. Another unintended consequence of the ACA is that individuals that choose not to pay their premiums and have their coverage terminated can reenter the exchange and enroll in a plan regardless of their pre-existing conditions so there is little incentive for some individuals to maintain their coverage.

Were you aware of the 90-day grace period? As a healthcare professional or provider, are you worried you don’t have adequate financial protection?

Michael L. Smith is an attorney and George F. Indest, III is president and managing partner, both at The Health Law Firm.
Courtesy of:

Sunday, November 17, 2013

New CMS-1500 Medi-Cal (California Medicaid) Guide for Use Beginning January 6, 2014

Medi-Cal has created a New CMS-1500 Medi-Cal Guide to show providers the fields that have changed on the new 02/12 version of the CMS-1500 claim form. Information submitted in the fields will be the same as information submitted previously on the old 08/05 version of the claim form.

Providers can refer to the CMS-1500 Completion or CMS-1500 Completion for Vision Care section in the appropriate Part 2 provider manual for claim completion instructions by field number. Side-by-side comparisons of the current and upcoming claim fields are available in the New CMS-1500 Medi-Cal Guide, which can be downloaded from the new Claim Form Updates page of the Medi-Cal website.

Old and New Claim Versions: Dates of Use
Beginning January 6, 2014, the Medi-Cal claims processing system will be able to accept and process the new 02/12 version of the CMS-1500. The old 08/05 version of the CMS-1500 will continue to be accepted and processed also, but only for three months, through March 31, 2014. Beginning April 1, 2014, only claims submitted on the 02/12 version will be accepted and processed.

Provider Manual Update Plan
The CMS-1500 claim form has been revised to accommodate the ICD indicator that will be required on claims in 2014 with the ICD-10-CM code rollout. Rather than update the entire provider manual to announce claim updates and then next year release the manual pages again with ICD-10 information, Medi-Cal has determined to approach provider manual updates as follows:
  • To serve the immediate need for claim completion instructions, the CMS-1500 Completion and CMS-1500 Completion for Vision Care manual sections will be updated. The sections are slated for release in the December 2013 Medi-Cal Update bulletins. A set of instructions for completing the new 02/12 version of the CMS-1500 will be added at the front of each section. The older 08/05 instructions will be retained at the back of the section.
  • Claim field names in the provider manual will continue as they appear on the 08/05 version of the CMS-1500. For example, Reserved for Local Use field (Box 19) will be retained and not changed to Additional Claim Information field (Box 19) until later in 2014.
  • Billing examples will be retained, as is, in the 08/05 version of the CMS-1500.
  • If it is determined that claim instructions must be updated before ICD-10-related manual pages are released in 2014, an analysis will be performed to decide if select manual pages should be updated and released.
The above cost-saving approach will allow several hundred manual sections to be updated only once.

Courtesy of:

Tuesday, November 12, 2013

New Influenza Virus and Hepatitis B Virus Vaccine Codes: Noridian/Medicare

MLN Matters® Number: MM8249
Related Change Request (CR) #: CR 8249
Related CR Release Date: May 2, 2013
Effective Date: November 20, 2012 (For code 90661); January 1, 2013 (For codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033)
Related CR Transmittal #: R2693CP Implementation Date: October 7, 2013

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8249, which provides instructions for payment and Common Working File (CWF) edits to be updated to include influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739 for claims with dates of service on or after January 1, 2013, but processed on or after October 7, 2013. The CR also provides instructions for payment and Medicare Common Working File (CWF) edits to be updated to include influenza virus vaccine code 90661 for claims with dates of service on or after November 20, 2012, processed on or after October 7, 2013. Make sure that your billing staffs are aware of these updates.

Vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739 are currently pending Food and Drug Administration (FDA) approval. Vaccines that are described by codes 90661, 90672, 90686, and Q2033 have already been approved.
The Centers for Medicare & Medicaid Services (CMS) will notify Medicare contractors once FDA approval is obtained for the vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739. In addition, Medicare contractors are adding Q2033 as an acceptable influenza vaccine code. As a result of CR8249:
  • Effective for claims with dates of service on or after January 1, 2013, vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 will be payable by Medicare.
  • Effective for claims with dates of service on or after November 20, 2012, code 90661 will be payable by Medicare.
Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination must take assignment on the claim for the vaccine.

On professional claims, for dates of service between January 1, 2013 and September 30, 2013, Medicare contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739. For dates of service on or after October 1, 2013, Medicare contractors will use Medicare Part B payment limits for these codes. Effective for dates of service between November 20, 2012, and September 30, 2013, contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine code 90661.

On institutional claims, hospitals (type of bill (TOB) 12X and 13X), skilled nursing facilities (TOB 22X and 23X), home health agencies (TOB 34X), hospital-based renal dialysis facilities (72X), and critical access hospitals (85X), payment will be based on reasonable cost for codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 with dates on service on or after January 1, 2013. For the same facilities billing code 90661 on or after November 20, 2012, the payment is also based on reasonable cost.

For Indian Health Services (IHS) facilities (including IHS critical access hospitals), comprehensive outpatient rehabilitation facilities, and independent renal dialysis facilities, payment will be based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP).
Medicare contractors shall deny claims for vaccines containing codes 90653, 90685, 90687, 90688, and 90739 if vaccines described by these codes have not obtained approval from the FDA by October 1, 2013. In doing so, they will use:
  • Claims Adjustment Reason Code (CARC) 114: Procedure/product not approved by the Food and Drug Administration.
  • Remittance Advice Remark Code (RARC) M51: Missing/incomplete/invalid procedure code.
  • Group Code: CO
Contractors shall also deny claims containing vaccine codes 90653, 90685, 90687, 90688, and 90739 if no product is located as a result of utilizing local pricing guidelines.

Additional Information
The official instruction, CR 8249, issued to your Medicare contractor regarding this change, may be viewed at This link takes you to an external website. on the CMS website.
Last Updated Nov 07, 2013

Back to School: Identify How ICD-10 Will Affect Your Practice

In order to be fully prepared for the October 1, 2014, ICD-10 transition, you need to know exactly how ICD-10 will affect your practice. Although many people associate coding with submitting claims, in reality, ICD codes are used in a variety of processes within clinical practices, from registration and referrals to billing and payment.
The following is a list of important questions to help you think through where you use ICD codes and how ICD-10 will affect your practice. By making a plan to address these areas now, you can make sure your practice is ready for the ICD-10 transition.
  • Where do you use ICD-9 codes? Keep a log of everywhere you see and use an ICD-9 code. If the code is on paper, you will need new forms (e.g., patient encounter form, superbill). If the code is entered or displayed in your computer, check with your EHR and/or practice management system vendor to see when your system will be ready for ICD-10 codes.
  • Will you be able to submit claims? If you use an electronic system for any or all payers, you need to know if it will be able to accommodate the ICD-10 version of diagnoses and hospital inpatient procedures codes. If your billing system has not been upgraded for the current version of HIPAA claims standards—Version 5010—you will not be able to submit claims. Check with your practice management system or software vendor to make sure your claims are in the HIPAA Version 5010 format and that your system or software can include the ICD-10 version of diagnoses and hospital inpatient procedures codes.
  • Will you be able to complete medical records? If you use any type of electronic health record (EHR) system in your office, you need to know if it will capture ICD-10 codes. Look at how you enter ICD-9 codes (e.g., do you type them in or select from a drop down menu) and talk to your EHR vendor about your system’s capabilities for ICD-10. If your EHR system does not capture ICD-10 codes and you use another terminology (SNOMED), you will still need ICD-10 codes to submit claims.
  • How will you code your claims under ICD-10? If you currently code by look up in ICD-9 books, purchase the ICD-10 code books in early 2014. Take a look at the codes most commonly used in your office and begin developing a list of comparable ICD-10 codes. Alternatively, check your software for an ICD-10 look up functionality.
  • Are there ways to make coding more efficient? For example, develop a list of your most commonly used ICD-9 codes and become familiar with the ICD-10 codes you will use in the future; and invest in a software program that helps small practices with coding.
Want more information about ICD-10?
Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Sign up for CMS ICD-10 Industry Email Updates from CMS.

Courtesy of: Centers for Medicare & Medicaid Services (CMS) Weekly Digest Bulletin

Thursday, November 7, 2013

How Late Payments, Patients can Throw off a Medical Biller's Day

By Marsha Sosebee from Physicians Practice

Dear Diary, even though it’s Monday, today started out with much promise of being a good day. The end of month collection percentage totals for last month looked great. The percentage of money in the over-120-day-and-aging bucket was down to 0.2 percent and the overall amount due on the accounts receivable report was down by $32,000. I had high hopes that the day would end as well as it began.

My first task of the day was to review the schedule to see which of today’s patients had a past due balance. Finding four such patients, I began to review their history and send necessary alerts to the receptionist. The first two patients had balances from surgeries and were making regular monthly payments as promised. So far so good. The third patient had owed a balance for almost two months and had not yet set up a payment plan, even though he had been back for a recheck appointment just last week. That’s where my hopes for the day began to sag a bit.

The fourth patient had been the victim of a car accident and one of our doctors had been called from the emergency room to do surgery. The hospital had not given us any insurance information on this patient, so I looked to see what information the patient had given at his first recheck appointment in our office. Nothing was written in the section for insurance. Great. As I read through the note history, I found a note from the receptionist that said, "At checkout, asked patient to pay on surgery balance. Patient responded that the accident was the other guy’s fault and that’s who would have to pay the bill." Further notes revealed his adamancy that he was not going to pay this surgery balance. We were at an impasse because our doctor was on main ER call that day and we were required to continue seeing him until treatment was complete. At this point, my hopes for the day were swinging mighty low.

I called the car insurance claims adjustor only to be told that the hospital bills had exhausted the MedPay limits on the patient’s automobile policy and the at-fault driver did not have car insurance. The patient’s attorney had already been in contact with them about a settlement but in all reality, it would probably end up going to court. The adjustor said that if a settlement was reached, it would be paid to the patient who would be responsible for using it to pay the remainder of his medical bills.

I added my note to the history and inserted a pop-up note that I needed to speak with the patient when he arrived. Judging by the previous encounter our staff had with him, I was not looking forward to his arrival at 10:30.

The next order of business on the “to do list” was to check status of pre-certs that had been requested last week. I called ABC insurance company first because three of the precertifications were theirs. I don’t know how so much changes in one week at insurance company, but apparently it can. I dialed the same number I had called the week prior to begin the precert process. After going through the maze of prompts, a person answered who informed me that I had reached the wrong department. I assured her I had chosen all prompts carefully. She asked for the number I had dialed originally. I told her 800-000-0000. She said that was the problem; that number was not for precerts at all. She agreed to transfer me to the correct department. The person in that department would have loved to help me, but they don’t handle precerts for that employer group. Again, I was transferred to the correct department. Four transfers later, I finally connected with a representative who said that if I had just dialed 800-000-0000 I would have reached her directly and avoided all of this unnecessary frustration. I’m glad she couldn’t see my expression through the phone.

Confident that I had at last reached the right person, I gave her the patients' information for whom I had requested precertifications. Two were in process she said, but the third request was not on file.

"Why not?" I demanded to know. I had sent all three sets of clinical information and photographs in the same envelope. If two were there, what happened to the third one, I wanted to know. The rep suggested that maybe I had forgotten to include the third one. I knew I had put all three in there. After 20 minutes of back and forth and being put on hold so she could check with other departments, she finally came back to the line to let me know it was found in the mail room. She informed me that I would have to send the photographs again because she was not able to locate them.

At this point, I gave up all hope for the day ending on a good note and I was pretty sure this was a good indication of how my week was going to be. It was also at this point that I wondered if other billers really faced the same frustrations as me. I also contemplated whether or not billers should automatically have a prescription of Prozac. Like some people have a jar of peppermints on their desk, maybe billers need a little jar of happy pills.


A frustrated biller

Article courtesy of Physicians Practice

Wednesday, November 6, 2013

Medi-Cal & Telehealth (California Medicaid)

Medi-Cal & Telehealth

The Department of Health Care Services (DHCS) considers telehealth a cost-effective alternative to health care provided in-person, particularly to underserved areas. Telehealth is not a distinct service, but a way that providers deliver health care to their patients that approximates in-person care. The standard of care is the same whether the patient is seen in-person or through telehealth.

DHCS’s coverage and reimbursement policies for telehealth align with the California Telehealth Advancement Act of 2011 and federal regulations. State law defines telehealth as “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site.” This definition applies to all health care providers in California, not just Medi-Cal providers.

Medi-Cal also complies with federal regulations for telehealth, which are the same for Medicaid as they are for Medicare. Medicaid regulations authorize telehealth using “interactive communications” and asynchronous store and forward technologies. Interactive telecommunications must include, at a minimum, audio and video equipment permitting real-time two-way communication, according to the Centers for Medicare and Medicaid Services.

Medi-Cal pays for current Medi-Cal benefits appropriately provided via telehealth:
 • Selected Evaluation and Management (E&M) services for patient visit and consultation.
 • Selected psychiatric diagnostic interview examination and selected psychiatric therapeutic services.
 • Teledermatology by store and forward.
 • Teleophthalmology by store and forward.
 • Transmission costs (up to 90 minutes per patient, per day, per provider).
 • Originating site facility fee.
 • Interpretation and report of X-rays and electrocardiograms performed via telehealth.

Please see the Medi-Cal Provider Manual: Telehealth for more information.

For additional information about Medi-Cal’s coverage and reimbursement telehealth policies, as well as resources for providers, please see the Telehealth Resources page.

For questions about submitting a claim for services provided by telehealth, please call the Telephone Service Center (TSC) at 1-800-541-5555.

Providers may email questions about Medi-Cal telehealth policy to

Medicare/Noridian New Waived Tests - Revised November 2013

New Waived Tests - Revised

MLN Matters® Number: MM8439 Revised
Related Change Request (CR) #: CR 8439
Related CR Release Date: October 28, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2804CP
Implementation Date: January 6, 2014

This article was revised on October 29, 2013, to reflect a new Change Request (CR). The CR corrects the spelling of "Premier Integrity Solutions P/Tox Drug Screen Cup." The transmittal number, CR release date and web link to the transmittal was also changed. All other information remains the same.

Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare Claims Administration Contractors (Medicare Contractors) for services to Medicare beneficiaries.

Provider Action Needed
If you do not have a valid, current, Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to your Medicare Carrier or A/B MAC for a Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.
CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The CPT codes that the Centers for Medicare & Medicaid Services (CMS) consider to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 8439, from which this article is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.
Make sure that your billing staffs are aware of these CLIA-related changes for 2014 and that you remain current with certification requirements.

Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the tests mentioned on the first page of the list attached to CR8439 (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.
The CPT code, effective date and description for the latest tests approved by the FDA as waived tests under CLIA are the following:  
  • G0434QW, January 23, 2008, Phamatech At Home 12 Drug Test (Model 9308T); 
  • G0434QW, January 23, 2008, Phamatech At Home 12 Drug Test (Model 9308Z); 
  • 81003QW, January 29, 2013, Henry Schein Urispec Plus Urine Analyzer;  
  • G0434QW, February 27, 2013, CLIA waived, Inc. Rapid Drug Test Cup; 
  • G0434QW, February 27, 2013, Clinical Reference Laboratory, Inc. Intelligent Transport Cup; 
  • G0434QW, February 27, 2013, Noble Medical Inc. Noble 1 Step Cup; 
  • G0434QW, February 27, 2013, Premier Integrity Solutions P/Tox Drug Screen Cup; 
  • G0434QW, February 27, 2013, US Diagnostics ProScreen Drugs of Abuse Cup; 
  • 84443QW, March 5, 2013, BTNX Rapid Response Thyroid Stimulating Hormone (TSH) Test Cassette (Whole Blood); 
  • 86308QW, March 11, 2013, Henry Schein OneStep Pro+ Mono {Whole Blood}; 
  • G0434QW, May 15, 2013, UCP Biosciences, Inc. UCP Home Drug Screening Test Cups; 
  • G0434QW, May 17, 2013, Alere Toxicology Services, Inc. Tox Screen Drugs of Abuse Test Cup; 
  • G0434QW, June 24, 2013, Advin Multi-Drug Screen Test; and 
  • 87880QW, July 3, 2013, Henry Schein OneStep Pro+ Strep A Cassette.
Additional Information
The official instruction, CR8439, issued to your MAC regarding this change may be viewed at This link takes you to an external website. on the CMS website.  
Last Updated Nov 04, 2013

Monday, November 4, 2013

The Affordable Care Act's Effect on Medical Billers

Article By Marsha Sosebee from Physicians Practice

The staunch proponents of Obamacare are joyously dancing in the streets amid a tickertape parade while those who vehemently oppose its inception are hunkered down in a fury of nail-biting anger. I think the vast majority of the population though are in a fog of miscommunication, false hope, and maybe some unnecessary worry.

What does Obamacare really mean to someone like me, an “in the trenches” medical biller? First of all it means that people will be looking to me to answer questions about their insurance now that Obamacare is here. But I have as many questions as they do. The one thing Obamacare has done is put everyone in the same boat, a boat called limbo. We don’t really know how it’s all going to work.

For example, I want to know how reliable eligibility verifications will be. I have claims on my desk right now for which I am fighting retro-termination denials. The day services were rendered, coverage was verified. When the claim was processed, the insurance denied saying the coverage was retro-terminated because the employer didn’t send in notification that the employee had been laid off. In the past, I’ve had denials because the insurance company said the Cobra premiums were not paid. The patient had cancelled checks showing that they did pay the premiums. That fight took me six months to finally receive payment for those outstanding claims. I feel justified in my level of concern for eligibility verification for these government-regulated exchange insurance plans.

Another area of concern for me is precertification. Considering the difficulty regular insurance companies exhibit on occasion, I can’t help but wonder how the governmental connection will affect the precertification process. Just last week, I spent four hours on the phone getting shuffled back and forth between the pre-certification and claims departments of a certain major insurer. The precertification department had told me prior to surgery that no precert was required. I documented the name, date, and time related to this call. Last week the surgery claim was denied because there was no pre-certification. I gave the claims department my documented information and was told that didn’t matter to them because in their system it said precert was required. They said they couldn’t help that the precert department had given me wrong information. I asked if they could get the precert department on the line with us so we could resolve this issue. The response was, “No, we don’t make outgoing calls to other departments.”

So I called the precert department back. They said they were correct, no precert was required and that I should just tell the claims department to pay the claim. I asked if they would please call the claims department for me to verify. That request was met with a prompt, “Once the service is rendered, we are out of the picture.

”Ultimately the issue was resolved, but only because I finally found someone who actually cared about solving the problem and didn’t just pass the buck. I look at instances like this which occur with more regularity that I am comfortable with and I can’t help but think it will there will be worse headaches than this with plans that are overseen by governmental agencies. Maybe we billers should stock up now on aspirin.

My take on the whole Obamacare plan is that making healthcare affordable is a great thing. And if that’s what the Obamacare plan was really doing, I would be more supportive of it. But I think it will do more harm than good. I can very easily see that small businesses will convert employees to part-time status to avoid the penalty. What will that do to families already finding it nearly impossible to stay afloat financially?

I have strong reservations about the government forcing anyone to get health insurance. So many people think that Obamacare is offering free insurance. This is not true. They are forcing you to pay for insurance and the cost of the insurance plans are not readily available. I was just on the website and I consider myself semi-tech savy. The only way I could find to be able to compare the cost and benefits of the different plans was to actually do your application first. Applying for something before you know the cost is what my dearly departed father would have called "buying a pig in a poke".

"It has been my experience in life that people who are trying to manipulate a situation for their own benefit will create a diversion to get your attention off the truth of what they are doing. I think Obamacare has created a diversion with false concern for the health and well-being of the Amercian people. What is its real agenda? It could be simply to rake in more money for the government or it could be something much more sinister. Whatever the case may be, the next several months are going to be very interesting to say the least.

Article Courtesy of: