Thursday, October 31, 2013

New Measures in Pay-for-Performance Programs

Pay for performance, or P4P as it is more commonly known, is not a new concept and some plans have been using this type of initiative with providers for a decade or more. Those providers that participate in Medicare's Physician Quality Reporting System (PQRS) — which uses a combination of incentive payments and payment adjustments to promote reporting of quality information — as well as those participating in large Blues plans, will be most familiar with this model.

The shift What is new is the shift away from P4P as a "bonus" structure and a shift toward an "earning" structure. That is, the extent to which payers are incorporating P4P into their payment strategies means that a portion (or percentage) of providers' revenue is "earned" through meeting P4P targets or measures.  These new models are referred to as "value-based," shifting away from straight fee-for-service payments to some combination of performance- and fee-based compensation, which puts some of the financial risk on providers. The hope is this type of compensation model will improve the quality of care, reduce medical costs over time, and improve patient outcomes. So you can think of the newer P4P models as Pay for outcomes, or P4O.  Under Medicare  The Affordable Care Act expands P4P efforts in hospitals through the establishment of a Hospital Value-Based Purchasing Program begun last year, where hospitals are rewarded for how well they perform on a set of quality measures, as well as on how much they improve in performance relative to a baseline.  The healthcare law also extends the Medicare PQRS program through 2014. However, beginning in 2015 the incentive payments go away, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced. This marks the real beginning of P4O, in my view, due to the setting of a "quality care" baseline against which the ability to earn will then be tied.

By commercial payers For commercial payers, value-based contracts are springing up around Patient-Centered Medical Homes (PCMHs) and accountable care organizations (ACOs). However, new and negotiated contracts for generalized services — that is, practices that are not technically a PCMH or ACO — are now typically being crafted with P4P/P4O components that allow practices to "earn" additional dollars or year-to-year increases in multi-year contracts through meeting specific measures and targets.  Theses measure are typically HEDIS-based (Healthcare Effectiveness Data and Information Set) which is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). Many of these measures are focused on high-cost conditions such as heart disease, diabetes, high blood pressure, as well as preventive measures like immunizations and medication management. New and changed measures for 2014 include breast- and cervical-cancer screenings.

 Commercial payers utilizing P4P measures typically have a combination of HEDIS-type "quality" measures as well as "self-reported" measures, where practices can report on items such as EHR implementation and use, and status in achieving NCQA programs such as Patient-Centered Medical Home (PCMH), diabetes, heart/stroke, and back pain recognition programs. In addition to NCQA measures, there is substantial investment underway by the Agency for Healthcare Research and Quality (AHRQ) and other public policy organizations to identify further evidence-based medicine practices that could be used for measurement. And the National Quality Forum (NQF) is leading focused efforts to collect and normalize data, and endorse additional performance measures.

Article By Susanne Madden of physicians Practice

Wednesday, October 30, 2013

Ten No-cost Ways to Improve Patient Satisfaction

Patient satisfaction is a big deal. It boosts patient attraction and retention, and it reduces the likelihood a patient will file a malpractice lawsuit. It also saves a practice time: Happy patients do not take up physician and staff time complaining. Finally, it is beginning to affect reimbursement. Already for hospitals, and soon for all physicians accepting Medicare, patient satisfaction scores will determine bonuses and penalties.

Unfortunately, physicians do not always understand what satisfies, or even delights, patients. They tend to believe that the biggest component of patient satisfaction is quality of care.  What they miss is that patients have no way to effectively evaluate the quality of care. Instead, patients rely on proxies, and those proxies have everything to do with how the physician and staff make the patient feel — emotionally.
Here are 10 ways physicians and staff can significantly increase patient satisfaction:

 1. Use the patient's name. People love to hear their own name.

2. Use an honorific (Mr., Ms., etc.) to address a patient, particularly if you want to be addressed as "Dr. Jones."

3. Wear easy to read nametags just below your right shoulder. First name only is fine for staff. The objective is to give the patient something better to say than "Hey, you," if she needs something.

4. Make eye contact with the patient as often as is practical. This indicates you are paying attention and engaged with the patient.

5. Tell the patient what to expect. This applies to medical assistants bringing a patient back to an examining room, physicians making referrals to specialists, and check-out staff recapping the billing for visits.

6. Let the patient know what you expect of him. If you need to enter data during the visit, for instance, say, "I am entering your information, but I am listening," to indicate he should keep talking. Say, "I have to enter this information. I'll be done in just a minute," to indicate that you need silence.

7. Give written visit summaries, patient education materials, and instructions. Patients forget an incredible amount of what is said during the visit by the time they get to their car. The ability to reference a written record reassures them.

8. At the conclusion of the appointment, make eye contact with the patient and say, "Take care." This phrase resonates with patients more than, "Thank you," "Have a nice day," or "See you soon."

9. Run on time, or close to it. This may be the primary way patients evaluate the regard the practice has for them.

10. Return phone calls and fulfill requests according to your posted protocol. It is only reasonable for a patient to assume that a practice out of control in some areas is out of control in others.

Please note that I did not mention coffee and Wi-Fi in the waiting room or birthday cards for patients.  Some patients may appreciate amenities and remembrances, but none will identify them as indicating caring and concern.  Behavior, sincere and consistent, is what convinces patients that they are respected and well cared for.

Article  By Carol Stryker of Physicians Practice

Improve Medical Practice Efficiency by Offering Group Visits

As reimbursement declines and overhead increases, many practices are struggling to keep up. But rather than attempting to squeeze more patient visits into each day, has your practice considered seeing more patients per visit?

Perhaps it should. The number of practices offering group visits has increased from about two percent to three percent just two years ago to about 10 percent this year, practice management consultant Owen Dahl recently told Physicians Practice.

Here's more on how a group visit works, what it entails, and why your practice may want to consider it.

How a group visit works. During a group visit, multiple patients with similar chronic conditions (such as diabetes, osteoporosis, congestive heart failure, or COPD) meet at the same time with their physician and other appropriate staff.  The visit is held in a private area in the practice, such as a conference room.
The visits may include the following components:

  • The taking of vital signs;
  • An educational piece, such as a 30-minute discussion with a nutritional counselor, dietician, exercise physiologist, podiatrist, or an ophthalmologist;
  • A group discussion, during which patients talk with each other about their particular needs, struggles, challenges, lessons learned, and so on;
  • And an individual assessment, during which the physician pulls patients out of the group individually for private exams.
"You see these 15 patients in an hour and half, so you're very efficient there," said Dahl. "The other thing that happens is you free up time slots on your schedule to see other patients."
How a group visit is reimbursed.  After the group visit, the practice bills the appropriate visit (99213 or 99214) for each patient that attends. "You don’t bill based on time, you bill based on the criteria for the level of visit they had," said Dahl, noting that documentation must support the level of code.

How a group visit benefits patients. Group visits provide patients with a support group facing similar issues, and they give patients an opportunity to receive more in-depth education about their condition. That often translates to better outcomes, said Dahl.

"You're actually improving patient care, and I say that with some conviction," he said. "The research that’s been done indicates clearly that there’s a positive outcome with patients being more compliant with their treatment plans ... seeking care, getting involved. There are all of these spinoff benefits that come together.

"How a practice can get involved. Assess your patient population to determine if you have enough patients with similar chronic conditions for which a group visit would be beneficial. Then, determine if enough of your patients would participate, said Dahl.

If you determine that a group visit is something you can and should offer, promote it to patients through one-on-one discussions, handouts, and if applicable, on your practice's website or patient portal.

Before the visit, require all participants to sign group-visit specific HIPAA forms noting that they understand that they will be talking about personal health information with other patients, and stating that they will keep the information shared during the group visit confidential.

Article By Aubrey Westgate of Physicians Practice

Do you offer group visits at your practice? What tips would you share with other physicians?

Ethics on Ending the Patient-Physician Relationship

Once you accept a patient into your practice, you are under an ethical and legal obligation to provide services to the patient as long as the patient needs them.  There may be times, however, when you may no longer be able to provide care.  It may be that the patient is noncompliant, unreasonably demanding, threatening to you and/or your staff, or otherwise contributing to a breakdown in the patient-physician relationship. Regardless of the situation, you must avoid a claim of "patient abandonment."  Abandonment is a tort, similar to negligence, defined as the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement.
There must be some harm from the abandonment.  The plaintiff must prove that the physician ended the relationship at a critical stage of the patient's treatment without good reason or sufficient notice to allow the patient to find another physician, and the patient was injured as a result.  Usually, expert evidence is required to establish whether termination happened at a critical stage of treatment.
A physician who does not terminate the patient-physician relationship properly may also run afoul of ethical requirements, and find himself before the medical board.  According to the AMA's Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.  Further, the patient's failure to pay a bill does not end the relationship, as the relationship is based on a fiduciary rather than a financial responsibility.

According to the AMA's Code of Medical Ethics, Opinion 8.115, you have the option of terminating the patient-physician relationship, but you must give sufficient notice of withdrawal to the patient, relatives, or responsible friends and guardians to allow another physician to be secured.

The Health Care District of Palm Beach County offers this advice regarding the appropriate steps to terminate the patient-physician relationship:

1. Giving the patient written notice, preferably by certified mail, return receipt requested;
2. Providing the patient with a brief explanation for terminating the relationship (this should be a valid reason, for instance non-compliance or failure to keep appointments);
3. Agreeing to continue to provide treatment and access to services for a reasonable period of time, such as 30 days, to allow a patient to secure care from another person (a physician may want to extend the period for emergency services);
4. Providing resources and/or recommendations to help a patient locate another physician of like specialty; and
5. Offering to transfer records to a newly-designated physician upon signed patient authorization to do so.

Following this protocol may be easier in some situations than others.  For example, if a physician has signed a covenant-not-to-compete, chances are the employer will not hand over the patient list upon notice of departure.  In instances such as these, you (in consultation with your attorney) may want to provide a model patient termination letter to the party withholding your patients' addresses, and request that the addresses and letter be merged for distribution to your patients. 
Ideally, you should not be in a contractual arrangement that makes contacting your patients difficult.  However, if you find yourself in this situation, work with an attorney to ensure that appropriate steps are taken.

Article  By Martin Merritt of Physicians Practice

Monday, October 28, 2013

Screening Services Approved Billing Medicare Patients (Noridian)

Noridian Healthcare Solutions (Noridian) has had increased call volume regarding claim denial for approved screening services.

If a service is truly a CMS approved screening service, providers should bill the appropriate screening ICD-9 "V code" diagnosis and procedure code. (Most routine/screening ICD-9 "V codes" are not payable.) If the service is diagnostic, providers must bill the appropriate diagnosis code supporting the medical condition for the billed procedure code. For view billable screening diagnosis codes, go to the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 18 at

See additional CMS preventive and screening service resources at:
Monitored Anesthesia Care (MAC) (00100-01999) used for screening services should only be done when the patient has one or more co-existing medical conditions. Anesthesia providers should use the QS modifier for MAC when one or more of the co-existing medical conditions are present. Providers must bill the diagnosis code for the co-existing condition along with the screening diagnosis code on the claim. The co-existing medical condition diagnosis code must be linked the service billed on detail line of the claim. If the patient does not have any co-existing medical conditions provider can bill for conscious sedation (99144-99150).

If there are questions in regards to payment, call the Provider Call Center or use the Interactive Voice Response (IVR) system to check a claim status.
Last Updated Oct 25, 2013
From Noridian

2013-2014 Influenza (Flu) Resources for Health Care Professionals

MLN Matters® Number: SE1336
Provider Types Affected

This MLN Matters® Special Edition article is intended for all health care professionals who order, refer, or provide flu vaccines and vaccine administration to Medicare beneficiaries.
What You Need to Know

Keep this Special Edition MLN Matters® article and refer to it throughout the 2013 - 2014 flu season.

Take advantage of each office visit as an opportunity to encourage your patients to protect themselves from the flu and serious complications by getting a flu shot.
Continue to provide the flu shot as long as you have vaccine available, even after the new year.
Don't forget to immunize yourself and your staff.


The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare Part B reimburses health care providers for flu vaccines and their administration. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.)

You can help your Medicare patients reduce their risk for contracting seasonal flu and serious complications by using every office visit as an opportunity to recommend they take advantage of
Medicare's coverage of the annual flu shot.

As a reminder, please help prevent the spread of flu by immunizing yourself and your staff!

Know What to Do About the Flu!

Educational Products for Health Care Professionals
The Medicare Learning Network® (MLN) has developed a variety of educational resources to help you understand Medicare guidelines for seasonal flu vaccines and their administration.
  1. MLN Influenza Related Products for Health Care Professionals
  1. Other CMS Resources
  1. Other Resources
The following non-CMS resources are just a few of the many available where you may find useful information and tools for the 2013 – 2014 flu season:
Beneficiary Information
For information to share with your Medicare patients, please visit on the Internet.

Update to the Provider Remittance Advice Impacts as a Result of the Jurisdiction E Part B MAC Transition

Noridian has identified an impact to the content of the provider remittance advices as a result of the transition of pending workload from Palmetto Government Benefit Authorizers (PGBA) to Noridian.

Providers may notice the Glossary, Group, Reason, MOA, Remark and Adjustment Codes section of their remittance may contain verbiage that does not match the services provided.  The group codes and liability assigned to payments and denials may also be incorrect.

One example providers may notice is for claims that previously displayed CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee Arrangement) for payment.  These paid claims may incorrectly display on the remittance as a PR-150 (Payer deems the information submitted does not support this level of service).  As of 9/20/2013, this has been updated in Noridian's system. Please be aware that remittances generated on or after 09/20/13 may still show the incorrect verbiage depending on the status of the claim when the system was updated.

Noridian is currently working to correct history and provide corrected remittance advices to impacted providers.  Additional updates will be provided when they are available.

10/22/13 Update: Noridian has completed updating a large part of claims history that contained incorrect provider remittance advice messages.  We continue to work to update any remaining claims with incorrect messages.

Corrected provider remittance advices for all claims that were part of the history correction are expected to be generated in the next few weeks.  Further information regarding the dates and generation of the remittances will be provided when they are available.

Last Updated Oct 24, 2013

Friday, October 25, 2013

Boost Medical Practice Collections by Cutting Down Patient Statements

By P.j. Cloud-moulds from Physicians Practice

Do you know how many patient statements are sent out at your practice? Do you know how high that A/R class is? These are two very important questions you need to ask yourself today. The numbers might shock you.

If you do find that the number of patient statements is too high, you can then start asking why this is the case. Here are some of the common reasons:

Your front office staff did not collect the patient copay, coinsurance, or deductible. If you have an up-to-date fee schedule, calculating the patient coinsurance and deductible is easy, and should be done at the end of the appointment prior to the patient walking out the door. Copays are easy to collect and should be collected at the beginning of the appointment.

Your front-office staff did not collect according to plan details. When verifying an insurance plan, sometimes the insurance company will provide incorrect information. Your staff may also be calculating the patient portion incorrectly. Be sure your staff is well trained in this area. It's costing you a lot of money if they are not.

 Patients are paying at the time of service, but those payments are not getting posted properly. This results in a nasty call from the patient stating that, “I paid, and will not pay again!” This is the epitome of poor customer service. Institute checks and balances at the end of each day to ensure payments are posted.

Patient “forgot their checkbook or credit card.” This is a line that you hear too often, and it's full of hot air. If the patient “forgets,” let him know that he can call in his payment by the end of the day, or he will incur a late payment fee. Yes, this is legal. If the patient can't pay now, he certainly won't pay in a month when he gets the bill.

Staff adjusts off a patient deductible. Your front-office staff performs the insurance verification, and sees that the patient has a $5,000 deductible of which only $352 has been met. Once the deductible is met, the patient is responsible for 20 percent of the allowed charges. Your front-office staff is reluctant to charge the patient the deductible amount for fear of being yelled at by the patient (who should already know her plan limitations, but most often does not) so staff charges her the co-insurance instead. This results in the patient getting a bill for the remaining amount. The angry patient then calls and yells at the staff stating, “I paid at the time of service!” Another example of poor customer service. Remember, you cannot adjust off a patient deductible.

The patient has Medicare and a secondary insurance. Since we are not allowed to collect monies from Medicare patients until Medicare pays its portion, we bill the secondary. If the secondary does not pick up all of Medicare's 20 percent, then the patient gets a bill. It's really difficult when some Medicare patients do not understand their secondary insurance has a deductible, or will not cover the entire 20 percent.

Just sending out statement after statement is a very poor way of running a business. Have a time limit of how many statements you will allow a patient to receive. Three months is a good rule of thumb. If patients need to be put on a payment plan, that's great, but put a time limit on that, as well. Your practice is not a bank, credit union, or credit card. It is a business, and no other business would allow goods and services to walk out the door before payment. Stop allowing patients to take advantage of your good nature.

Article taken from Physicians Practice

AMA Insight, No Matter Which Side You Are On (Humor)

The American Medical Association has weighed in on Obama's new health care package. The Allergists were in favor of scratching it, but the Dermatologists advised not to make any rash moves. The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve. Meanwhile, Obstetricians felt certain everyone was laboring under a misconception, while the Ophthalmologists considered the idea shortsighted.

Pathologists yelled, "Over my dead body!" while the Pediatricians said, "Oh, grow up!" The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it. Surgeons decided to wash their hands of the whole thing and the Internists claimed it would indeed be a bitter pill to swallow. The Plastic Surgeons opined that this proposal would "put a  whole new face on the matter". The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea. Anesthesiologists thought the whole idea was a gas, and those lofty Cardiologists didn't have the heart to say no.

In the end, the Proctologists won out, leaving the entire decision up to the a-
a-a-a-a  - - - - - - people - - - - in Washington.  (sorry can’t pass on the swear word that was there – best to read between the dashes!)

Medicare Jurisdiction E Part B Updates

Payment Rules Notice

Although we are still assessing the impact of the partial government shutdown on completion of the calendar year 2014 Medicare fee for service payment regulations, we intend to issue the final rules on or before November 27, 2013, generally to be effective on January 1, 2014. The impacted regulations include:
  • Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CMS-1526-F)
  • CY 2014 Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (CMS-1601-FC)
  • CY 2014 Home Health Prospective Payment System Final Rule (CMS-1450-F)
  • Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule with Comment Period (CMS-1600-FC)
Source: LEARNRESOURCE-L E-mail Update, National Institutes of Health, U.S. Department of Health and Human Services dated October 23, 2013

Wednesday, October 23, 2013

The Evolution of Government Intrusion on the Medical Profession

By Martin Merritt from Physicians Practice

This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.

I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.  

This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find.  Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.

Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.

For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)

“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.

Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.

Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.

Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.

Many fear, and rightly so, that as healthcare insurance exchanges offered at become fully operational, the federal takeover of the practice of medicine will soon be complete.

In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.

Courtesy of Physicians Practice

“Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet — Released

The “Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet (ICN 908826) was released and is now available in downloadable format. This fact sheet is designed to provide education on the Health Insurance Marketplace under the Affordable Care Act. It includes information health care professionals need to know about the Marketplace, an explanation of how the Affordable Care Act expands access to health coverage, and an explanation of the Marketplace, how it affects health care professionals and their patients, and resources.
From Medicare Learning Network eNews update.

Health Professional Shortage Area (HPSA) Bonus Payments - 2014 Update

MLN Matters®Number: MM8463
Related Change Request (CR) #: CR 8463
Related CR Release Date: September 27, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2794CP
Implementation Date: January 6, 2014

Provider Types Affected

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

Provider Action Needed
Change Request (CR) 8463, from which this article is taken, alerts you that the annual HPSA bonus payment file for 2014 will be made available by the Centers for Medicare & Medicaid Services (CMS) to your Medicare contractor and will be used for HPSA bonus payments on applicable claims with dates of service on or after January 1, 2014, through December 31, 2014. These files will be posted to the internet on or about December 1, 2013. You should review  This link takes you to an external website.  on the CMS website each year to determine whether you need to add the AQ modifier to your claim in order to receive the bonus payment, or to see if the ZIP code area in which you rendered services will automatically receive the HPSA bonus payment. Note that Medicare contractors will continue to accept the AQ modifier for partially designated HPSA claims. Please be sure that your staffs are aware of this update.

Section 413(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated an annual update to the automated HPSA bonus payment file. CMS automated HPSA ZIP code file is populated using the latest designations as close as possible to November 1 of each year. The HPSA ZIP code file will be made available to CMS contractors in early December of each year. CMS contractors shall implement the HPSA ZIP code file and for claims with dates of service January 1 to December 31 of the following year, shall make automatic HPSA bonus payments to physicians providing eligible services in a ZIP code contained on the file.

Additional Information
The official instruction, CR8463, 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 Oct 21, 2013

Tuesday, October 22, 2013

What is PQRS?

What is PQRS?

Created in March 2007, the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) established a financial incentive for eligible healthcare professionals to participate in a voluntary quality reporting program. In 2011, CMS changed the program name to the Physician Quality Reporting System (PQRS).

Outcome is qualified to report all Individual Measures and Measures Groups, which can be reported to CMS by physicians and other caregivers in hospitals or physician practices. The PQRS offers the opportunity to earn a 0.5% incentive payment.

Learn more at

Outcome PQRS Registry: a simpler approach to getting your reimbursement

The PQRS registry by Outcome, A Quintiles company, is a CMS qualified, web-based registry that provides practices with a simpler approach to receiving their reimbursement.

The registry approach significantly simplifies the reporting process by using clinical data that clinicians are accustomed to and separating the process from the claims submission process. Data can be entered in the registry at any time throughout the year and then is reported as a single transmission to CMS by Outcome at the end of the reporting period (e.g. annually).

Leverage Existing Data
Our unique registry allows practices to leverage data that you have already collected and reduces data entry with an upload tool and integration capabilities, allowing data exchange to and from other practice systems, including practice management systems and electronic health record (EHR) systems.
Configurable by Provider
Whether you are a one-physician or a multi-specialty medical group, each practice enrolled receives an account tailored to their requirements and has the ability to select their measures, choose the reporting time period, view the data that has already been collected, and add additional data if needed. Physicians who also participate in other Outcome programs, such as our hospital-based programs and programs with physician and surgical specialty societies, may also be able to see data from those programs in their account.

Advice on Best Implementation
Our PQRS team has analyzed PQRS specialty by specialty to find the most efficient measure selections (least work effort required approach for each specialty). Our knowledgeable physician-led team is available to provide practices with guidance on the most efficient and effective methods to report their PQRS measures based on physician specialty requirements.
Electronic Prescribing (eRx) Incentive Payment
The Outcome registry offers practices the opportunity to participate in the CMS eRx Incentive Program and qualify for the 0.5% eRx incentive payment through the same program—at no additional cost. The Outcome registry includes the option to collect the appropriate eRx measure and Outcome transmits the data to CMS.

 Benefits of the PQRS Registry by Outcome, a Quintiles company
• Eligible professionals who successfully report a designated set of quality measures on claims may earn a bonus payment
• Reduces data entry with an upload tool and allowing for data exchange to and from other programs and practice systems, including practice management and electronic health record systems
• Support from our highly-trained Help Desk team, dedicated to providing training and real-time technical support and available by phone and email
• Provides support to help physicians choose which quality measures are most suitable to their area of practice
• Creates a registry view of data for quality improvement
• Registry method allows clinicians to focus on patient care and no need for changing coding practices with CPTII and G codes
• Provides flexibility in participation by separating PQRS reporting from claims submissions so that data can be entered retrospectively or concurrently
• Allows physicians to see their results before they transmit to CMS

View a Webinar Register today at
Learn More For more information, please contact us:
(617) 715–6898

What is PQRS?
Created in March 2007, the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) established a financial incentive for eligible healthcare professionals to participate in a voluntary quality reporting program. In 2011, CMS changed the program name to the Physician Quality Reporting System (PQRS).
Outcome is qualified to report all Individual Measures and Measures Groups, which can be reported to CMS by physicians and other caregivers in hospitals or physician practices. The PQRS offers the opportunity to earn a 0.5% incentive payment.
Learn more at

Noridian Telephone Reopening: Requests Containing Ambulance, Critical Care and MolDX Services No Longer Accepted (Medicare)

Effective immediately, claims containing the below procedure codes now require documentation be submitted with their Reopening request and will no longer be corrected via a Telephone Reopening.
  • Ambulance: A0021-A0999
  • Critical Care: 99291 and 99292
  • Molecular Diagnostic (MolDX): 81200-81383, 81400-81479, 88380-88381, G0452, 81479, 84999, 85999, 86849, 87999, 88199, 88299, 88399, 89398, 83890-83914, and 88384-88386
When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to
Last Updated Oct 17, 2013 By Noridian

Thursday, October 17, 2013

How Practices Should Deal With Late Patients

By Marisa Torrieri from Physicians Practice

Even if practices have clear-cut policies on handling no-show patients, dealing with late patients — especially those who are chronically late to appointments — is another issue altogether.

Late patients can throw off a practice's schedule and affect the amount of time physicians can spend with patients, especially in a small practice. Therefore, dealing with them raises questions: Should you accommodate late patients right away? Can you show them the door?

Declining to see a patient isn't usually an option, as it can be downright unethical and could actually cause a legal problem.

"Turning patients away if they're arriving late — you must talk to your malpractice carrier about that," says Elizabeth Woodcock, an Atlanta-based healthcare consultant, trainer, and author of "Mastering Patient Flow to Improve Efficiency and Earnings." "And you need to understand any malpractice risks you're taking by implementing such a policy. Unfortunately, if they have a heart attack on your doorstep as they're walking away, it's going to be your problem."

It's important to try and get the patient in to see someone if possible, such as a nurse or another doctor, says Ericka L. Adler, a partner at the firm of Kamensky Rubinstein Hochman & Delott, LLP, and contributor to Practice Notes,'s blog. If a patient does not get required care that can come back to hurt the physician if something happens to the patient, she adds.
Practices do have some options, however.

The first thing a practice can do to diminish late patients is make sure it is generally running on time.

"Please, please make sure that your practice is running on time," says Woodcock. "The practices that yell the loudest about chronically late arrivers are the ones who run late themselves. If the doctor is always running an hour behind, I'm going to run an hour behind [as a patient]."

Only the doctor or another healthcare provider can determine how important it is to see a given patient quickly.

Woodcock suggests that if a patient is more than 20 minutes late, front-desk staff should contact the clinical team and see how soon a patient should be seen.

But for future appointments, chronic lateness may qualify as a valid reason to dismiss a patient entirely if they don't change their behavior.

At Performance Pediatrics in Plymouth, Mass., late patients — those who are more than five minutes late — are treated the same as no-show patients. On the first and second offenses, they're sent a warning letter. On the third offense, they're told they will be dismissed if the problem continues. And on the fourth offense, they are asked to find another provider.

"If you're five minutes late, everyone is five minutes late," says administrator Leann DiDomenico McAllister, adding that sometimes traffic can be bad on a particular day. "But we're talking about people who are a half-hour late. Or people who call an hour before their appointment because they forgot their kid had a baseball game."

Article By Marisa Torrieri from Physicians Practice

Patient Education: Medicare Open Enrollment (October 15, 2013 - December 7, 2013): Help Your Patient's Stay Informed!

This one time of year enrollment period is your chance to review your health care coverage and see if you need to make any changes, or if you're staying with the plan you already have.
This year, you may hear a lot about the Health Insurance Marketplace. The Marketplace Open Enrollment period (October 1, 2013–March 31, 2014) overlaps with the Medicare Open Enrollment period. The Marketplace is designed to help people who don't have any health coverage. If you have health coverage through Medicare, the Marketplace won't have any effect on your Medicare coverage
Throughout the next few months, information about your Medicare benefits will be available in many places:
  1. In the mail
  • Look through your mail
  • Look through the Medicare & You handbook
  1. On your computer
  2. In newspapers, magazines, TV and radio
Enjoy the choice and take control over your health care coverage. Protect your personal information and your identity. Plans aren't allowed to call or come to your home without an invitation from you. And, it's against the law for someone who knows that you have Medicare to sell you a Marketplace plan.
Medicare Open Enrollment only comes once a year.
Source: The Medicare Blog, published 10/01/13 by CMS at
Last Updated Oct 14, 2013

Physicians Need Business Training to Run their Practices Well

By Rebecca Fox, MD of Physicians Practice

Once physicians graduate medical school and complete the internship year, they can get unrestricted licensure in most states to practice medicine and surgery. However, I doubt that very few people would choose a doctor that had only these credentials and did not have extensive residency training and board certification in their specialty. As physicians, we spend an incredible amount of time and mental energy mastering the extensive body of knowledge that we need to practice medicine competently.

However, when we get out of our medical training, we are suddenly faced with the truth of the matter: We have no clue how to run a business! We are a really smart group of people that have not received the proper instruction for the business world.

If there is one thing I know about doctors, when we do not know something, we tend to disengage. We want to know what to do in order to help people. If we don’t know what to do, we retreat. We do it with patients and we do it with the business side of our practices, usually with poor results.

It is really hard as a physician to deal with a patient’s complaints if you don’t know what to do. It is easier to dismiss the topic and move on to something you feel competent with in order to help the patient. To give you an example, when I was faced with a very obese (72 pounds) two-year-old boy, my first reaction was to refer to pediatric endocrinology because I did not know how else to address the situation. However this little boy had no endocrine effects from his extreme obesity (yet!) so no endocrinologist would see him. Therefore, I was on my own to figure out what to do. Rather than to not address the problem, I sought to educate myself on pediatric obesity. I went to a continuing education course specifically to learn what to do for obese and overweight patients. I read further references and journals. I learned the proper approach and evaluation of these patients and now feel competent dealing with this subject; therefore I can help my patients.

But what about my practice? As I have written before, a medical practice needs the same level of care and attention as a patient in order to stay healthy and thrive. As long as everything is running well and the bills and payroll are met, it is easy to ignore or avoid the details. But when trouble arises, the physician owner(s) must be able to diagnose and treat their business. If they do not know how, then further education is necessary.

About four years ago, my practice went through a financial crisis after a year in which we had a "perfect storm" of events that drove us into red ink. My senior partner had a death in the family and the two junior partners had just attained this ownership level (and thus were inexperienced in all that is required of an owner). My office manager had been on the job for about two months at the point.  I had to deal with this looming disaster alone. I very quickly learned about financial analysis. The situation was so dire we considered having to lay off a provider. My office manager took an aggressive approach to cutting costs and it was my responsibility to increase revenue generated by the providers. Within 10 months, the practice had a complete financial turnaround and was back in the black. We have been solvent since that time.

So, how can physicians get the education they need to at least speak the language of office managers? They don’t have to go back to graduate school for an MBA. They can start slowly by reading journal articles about the business and management of medical offices as well as the multitude of business books on the market today. Many medical professional associates have resources as well.

One excellent source of education and information is Medical Group Management Association (MGMA). I have been attending the MGMA conference for the past three years. I have gained an incredible amount of education and knowledge that has improved my ability to guide the office manager and has given me skills to deal with financial matters and human resource challenges. I received education about management and feel that I am a better physician owner of my large pediatric practice. Additionally, the MGMA is very well versed in ongoing changes with government mandates and insurance company requirements.

Don’t get me wrong. I definitely want to leave management to the professionals and do what I am good at which is seeing patients (and generating revenue). But in order to create the kind of practice that my partners and I want, we have had to get more involved in the management issues; not to replace our office manager but to support her to do her job successfully. The combination of an effective office administrator along with the full support and understanding of the physician owners allows a seamless approach to our practice of 14 providers and over 40 employees.

By Rebecca Fox, MD of Physicians Practice
Courtesy of:

Workers' Compensation Plans: Getting Patient Claims Paid

If you accept workers' compensation patients at your practice, it's a good idea to review the contracts for some of the finer details of how you will be paid. There are a few areas that you can look at today that will help you be paid tomorrow:

• State where the workers' compensation plan originated from. Believe it or not, different states use different codes. If you are seeing a patient for an extended visit and often code the same you would a patient that has Medicare for the same visit, you may not be getting paid. This can also be said that if you are coding for multiple workers' compensation patients, and one is an out of state plan, you may be paid for one and not the other using the same code. Investigate those adjustments to make sure this is not the case. You can find the codes you should be using in your contract, or at worst, you can call another physicians office in the state the plan originates from and ask them what code they use.

What codes are actually paid by workers' compensation. Some workers' compensation plans will pay for a specific treatment, and others will not. It's important to track these items so you are aware of what will and won't pay. Otherwise, you are giving away care and losing a lot of money in the process.

• Oftentimes whether or not you are paid will simply rely on what is on the authorization form that came from the nurse case manager or adjuster. If there is something you'd like to do, and do not see it on the authorization, chances are you won't be paid for it on that appointment. Best to have your front-desk staff call and obtain authorization for the treatment you wish to perform. Sometimes you can get this authorization in as little as a few days up to several weeks, so plan accordingly.

Are you contracted with Medrisk, but not Universal Smart Comp? If Universal Smart Comp is the actual payer on the claim, you won't be paid. I know this seems confusing, but when your staff verifies the insurance and contacts the adjuster, it's best to ask, "Who is the payer?" If it is a company you are not contracted with, you can request another payer whom you are contracted with.

Regardless of the reason for a denial, it is so important to really know and understand your contracts. There may be tips and ideas for getting paid that adjusters are not willing to share after-the-fact once the denial has happened. Many are not very helpful or are just plain hard to get a hold of.

With the changes coming over the next several months, I've found that workers' compensation groups are buying each other up, merging or partnering strategically like the big payers (Wellpoint with Blue Cross and Amerigroup, Aetna, and Coventry, etc.) this may bring many changes to the workers' compensation reimbursement structure.

As always, know your payer mix, know why your adjustments are as high as they are, and read your contracts closely.

By P.j. Cloud-moulds Courtesy of: Physicians Practice

Monday, October 14, 2013

The Affordable Care Act and Model 4 Bundled Payments for Care Improvement

MLN Matters® Number: MM8070 Revised
Related Change Request (CR) #: 8070
Related CR Release Date: June 27, 2013
Effective Date: July 1, 2013
Related CR Transmittal #: R1251OTN
Implementation Date: July 1, 2013

This article was revised on September 23, 2013, to add clarifying language on page 3 (bold). This article was previously revised on July 26, 2013, to reflect a revised Change Request (CR). The CR added Part B MAC responsibility to the CR's business requirement 18.3. The release date, transmittal number and link to the CR were also changed. All other information remains the same.

Provider Types Affected
This MLN Matters® Article is intended for hospitals, physicians, and non-physician providers participating in the Model 4 Bundled Payments for Care Improvement (BPCI) initiative and submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article provides an overview of Medicare's implementation of the Model 4 Bundled Payments for Care Improvement initiative. General program information is provided along with separate sections containing information of special interest to hospitals and physicians and non-physician providers. It addresses issues related to readmissions, claims crossover, remittance advice, and claims submission, among others. This pilot program is being conducted under the Centers for Medicare & Medicaid Services (CMS) Innovation Center's model testing authority. The program is slated to be implemented in October 2013.

The Affordable Care Act provides a number of new tools and resources to help improve health care and lower costs for all Americans. Bundling payment for services that patients receive during a single episode of care, such as heart bypass surgery or a hip replacement, is one way to encourage doctors, hospitals, and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. Such initiatives can help improve health, improve quality of care, and lower costs.
CMS is working in partnership with providers to develop models of bundling payments through the BPCI initiative. On August 23, 2011, CMS invited providers to apply to help test and develop four different models for bundling payments. Model 4, one of these four models, is discussed in this article. In Model 4, the episode of care is defined as the acute care hospital stay and includes inpatient hospital services, Part B services furnished during the hospitalization, and hospital and Part B services for related readmissions.

Information in this article is based on the change requests implemented for Bundled Payments for Care Improvement Model 4, including CRs 7887, 8070, and 8196.

General BPCI Model 4 Information

Beneficiary Eligibility
In order to be eligible for Model 4, the beneficiary must meet the following requirements:
  • Beneficiary is eligible for Part A and enrolled in Part B;
  • At the time of admission, beneficiary either (a) has at least 1 day of utilization left and that day is
  • also a day of entitlement or (b) has at least one lifetime reserve day remaining;
  • Beneficiary does not have End-Stage Renal Disease;
  • Beneficiary is not enrolled in any managed care plans; 
  • Beneficiary must not be covered under the United Mine Workers; and
  • Medicare must be the primary payer.
If the beneficiary does not meet all of these requirements, the following codes will be assigned to rejected or cancelled NOAs:
  • Claims Adjustment Reason Code (CARC) B5: Coverage/program guidelines were not met or were exceeded.
  • Remittance Advice Remarks Code (RARC) N564: This patient did not meet the inclusion criteria for the demonstration project or pilot program.
Model 4 Bundled Payment Provision
  • Hospitals that participate in the BPCI Model 4 initiative will receive a prospectively established bundled payment for agreed upon Medicare Severity Diagnosis Related Groups (MS-DRGs).  
  • This will not apply to claims that are paid on a transfer per-diem basis.
  • This payment will include both the DRG payment for the hospital and a fixed amount for the Part B services anticipated to be rendered during the admission. Separate payment for providers' professional services rendered during the inpatient hospital stay will not be made.
  • Participating Model 4 hospitals will receive a Model 4 payment and will be responsible for payment to providers who would otherwise be paid for professional services under the Physician Fee Schedule (PFS). As such, physicians and non-physician practitioners should seek payment for professional provider services from the Model 4 hospital. 
  • Per the conditions of the Agreement between CMS and the Model 4 hospital, payment to physicians and non-physician practitioners must be made at a rate that is equivalent to the amount that would otherwise apply under the PFS, unless a different amount has been agreed to in writing by the Model 4 hospital and the physician.
  • Claims from physicians will be processed as no-pay claims if they occur between the inpatient hospital admission and discharge date in order to prevent duplicate payment of physicians under the bundled payment.
Co-payments, Co-insurance, and Deductibles
  • The regular Part A deductible, including the Part A blood deductible, and daily coinsurance amounts (when applicable) will continue to be applied to the claim. 
  • The fixed Part B portion of the negotiated bundled payment will first be applied to the Part B deductible, if applicable. 
  • A fixed Part B copayment will be applied to the claim. This will be the responsibility of the beneficiary and will be calculated as an approximation of what the Part B coinsurance would have been in the absence of Model 4.
  • Both the copayment and the deductible to be paid by the beneficiary for the Part B services will appear on the MSN along with the Part A deductible and any applicable coinsurance.
Payments made under Model 4 have no rights of appeal, except in the case of calculation errors.
  • RARC N83: No appeal rights. Adjudicative decision based on the provisions of a demonstration project.
Information for Hospitals
Notification of Admission (NOA)
Hospitals participating in this initiative should submit a Notice of Admission (NOA) when a beneficiary expected to be included in the model is admitted. Timely filing of the NOA allows subsequent Part B claims submitted before the hospital claim to be properly processed as "no-pay" claims, which indicates that payment for these claims are to be included in hospital payments under Model 4. By extension, these Part B claims will then be included timely on weekly Part B reports provided to the hospital to be used in calculating payments for Part B providers.
  • Hospitals will be paid a $500 payment upon submission of the NOA and will receive the balance of the prospectively established bundled payment when the hospital claim is processed.
    • RARC N568: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative.
    • If the patient ultimately does not qualify for a Model 4 prospective payment based on the MSDRG ultimately assigned to their inpatient stay, or if the NOA is cancelled, the $500 NOA payment will be recouped.
    • Medicare systems will initiate a "look back" into the claims history records upon receipt of a canceled NOA to identify Model 4 BPCI claims- i.e., Part B physician or other professional claims - which were processed as "no pay" as a result of the NOA being opened. If such claims were processed, the Medicare contractor will adjust the claims automatically and remit payment for services rendered based on regular Medicare Fee-for-Service claims processing rules.
    • Hospitals must submit the final claim within 60 days of the beneficiary's hospital admission or submit an interim claim during that time period to demonstrate that the beneficiary is still an inpatient. Otherwise, the beneficiary will be considered not subject to episode payment and the $500 will be recouped.
      • The following codes will be assigned when a Model 4 claim matches an NOA for admission date and beneficiary, but not provider.
        • CARC 208: National Provider Identifier - Not matched
        • RARC N562: The provider number of your incoming claim does not match the processed Notice of Admission (NOA) for this bundled payment
      • The following codes shall be assigned when an NOA is cancelled because a matching claim is not received within 60 days. A match consists of beneficiary, admit date, and provider.
        • CARC 226: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete
        • RARC N560: This pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.
Model 4 hospitals will not be paid for readmissions that occur to the same hospital (i.e., another admission with a date of admission within 30 days of discharge of the Model 4 stay) under this model unless the MS-DRG assigned to that readmission is expressly excluded as unrelated to the MS-DRG assigned to the original admission.
  • Unrelated readmissions have been defined by CMS, and a list of DRGs defining unrelated readmissions has been provided for each included MS-DRG to every Model 4 participating hospital. This list can also be found on the Bundled Payments collaboration site, accessible to Model 4 Awardees.
  • Related readmissions to a hospital other than the original treating hospital, as well as payments for physicians' services during related readmissions to hospitals other than the original treating hospital, will be reconciled retrospectively by a BPCI payment reconciliation contractor and payment will be recouped, as applicable, by the Model 4 awardee.
    • If claims for a Model 4 anchor admission and a readmission are submitted out of order, the readmission claim will be canceled and must be resubmitted to receive payment. The following codes will be used in this situation:
      • CARC 249: This claim has been identified as a readmission.
      • RARC N561: The bundled payment for the episode of care includes payment for related readmissions. You may resubmit your claim to receive a corrected payment.
Payment Rate Updates and Adjustors
Payment rates may be updated as often as quarterly to allow for ongoing updates to Medicare payment rates, including regular recurring changes made to the Physicians Fee Schedule (PFS) and Inpatient Prospective Payment System (IPPS). Indirect Medical Education (IME) and Disproportionate Share Hospital (DSH) payments, as well as outlier payments and hospital capital payments to Model 4 hospitals will be calculated based on the non-discounted base DRG payment that would have been made in the absence of the model. This is true for both anchor admissions and related readmissions to the Model 4 hospital. In the case of readmissions, these payments will be denoted by the following:
  • CARC 249: This claim has been identified as a readmission.
  • RARC N524: Based on policy this payment constitutes payment in full.
Other applicable payment adjustors will also be calculated based on the base DRG that would otherwise have applied to the case, as opposed to the prospectively established amount paid through this initiative, which will be higher as it includes payment for Part B services in addition to the base DRG payment.
Information for Physicians and Non-Physician Providers
Claims Submission and Processing
Physicians and non-physician practitioners shall submit claims for dates of service during an episode of care included in Model 4 BPCI as usual.
Physicians and non-physician practitioners shall be required to accept assignment for all claims covered under the Model 4 BPCI payment.
For those Part B services rendered during a Model 4 admission or a related readmission to that Model 4 hospital, Medicare will process claims as no-pay. In processing no-pay professional claims, Medicare will assign the following:
  • CARC 234: This procedure is not paid separately.
  • RARC N67: Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or, if you furnished these services in another location on the date of admission or discharge from a demonstration hospital. If services furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.
Physicians submitting claims should take care not to include on the same claim services that are both within the dates (admission and discharge) of a Model 4 BPCI episode and outside the dates of the episode. If such claims with both Model 4 and non-Model 4 services are received, Medicare contractors will reject the claims and advise the physician to separate the services and rebill. The following remittance messages will be used in this situation:
  • CARC 239: Claim spans eligible and ineligible periods of coverage. Rebill separate claims. 
  • RARC N61: Rebill services on separate claims.
Incentive Payments
Bonus or incentive payments calculated by CMS, such as HPSA bonus payments, will not be affected by physician or non-physician practitioner participation in the Bundled Payments initiative.
Participation Declination
Physicians have the right to decline participation in this program. Declination will be indicated by including a HCPCS modifier on each claim. Further details will be provided at a future date.
Part B services provided during a related readmission to the original treating hospital will not be paid separately. If Part B claims were processed prior to receipt of the hospital's readmission claim, Medicare will take steps to recover payments to the physician.
  • CARC A1: Claim/Service Denied; and
  • RARC N68: Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment to the facility. You must contact the facility for payment. Prior payment made to you by the patient or another insurer for this claim must be returned within 30 days. 
Claims Crossover
In association with this initiative, CMS will make changes to allow for the reporting of two new Claim Adjustment Reason Codes (CARCs) within the 2320 Claim Adjustment Segment (CAS), so that supplemental payers can more easily determine these amounts when adjudicating Medicare Health Insurance Portability and Accountability Act (HIPAA) 837 institutional Coordination of Benefits (COB)/crossover claims.
  • CARC 247 will be defined as "Part B deductible on a Part A claim." 
  • CARC 248 will be defined as "Part B coinsurance on a Part A claim."
  • An adjusted RARC M137 will be defined as "Part B coinsurance under a demonstration project or pilot program.
This initiative will also result in the reporting of a new value code within the 2300 Health Care Information Codes (HI) Value Information (qualifier BE) portion of outbound HIPAA 837 institutional COB/crossover claims.
Additional Information
The official instruction, CR8070, issued to your Medicare contractor regarding this change may be viewed at on the CMS website. In addition, CR8196 is available at  and CR7887 is available at on the CMS website.
Last Updated Sep 26, 2013

Medical Billing Disputes: Finding Peace between Patients and Billers : Don't Be This Billing Service!

Your front-office staff is great. They check patients in, smile, schedule, and do everything right. The doctor or nurse sees the patient, listening intently for any clue that might help them solve whatever the problem. The patient leaves happy.

Then the bill arrives. The patient has a coinsurance they need to pay, and are very willing to do so, but it appears something has gone wrong with the insurance payment amount. They call the number on the statement to pay the bill, and get a not-so-friendly customer service representative. Things go downhill from there. A month later, the patient comes back into the office beside themselves, acting like a lunatic waving a bill around. Once you bring them into a private room away from the rest of your patients, you find out the problem: The patient has been fighting with your billing company for over a month to get a better understanding of what has happened.

This scenario happens far too many times. The office provides excellent service and the billing department — not so much. What is a practice manager to do? First, try to identify the actual problem and go from there.

Here are some tips on conflict resolution between your practice, the patient, and the billing department.

1. Identify the person in the billing department who the patient has been dealing with. Find out the rest of the story, as it could be the patient only had one interaction with the billing department, and the employee could have been trying to explain that the bill was part of the patient deductible and coinsurance. When patients don't want to hear what they don't understand, they start to argue.

2. Once you have a clear understanding of the problem, find out where the customer service portion of the patient experience failed. If it was lack of follow up with the patient or if the representative was indeed rude, that should be addressed with the billing department's manager.

3. Take this opportunity to create a plan with the billing manager to address overall customer service opportunities within the department and how you would like a very specific level of customer service to your patients.

This should include:
  • Friendly customer service representatives for your patients.
  • If the patient is not satisfied with the level of service, they should be allowed to speak with the manager immediately.
  • Follow up with patients. If the representative says, "Let me call you back on that," a phone call best be made within a specific time frame; in most cases 24 hours in a good rule of thumb.
  • • If your office is unsure how an insurance is going to pay a claim and the patient needs to be seen multiple times for similar treatments, it is reasonable to ask the billing department to follow a claim from beginning to end. They can then call and let your office know if the insurance is imposing a copay, coinsurance, or deductible for the patient to pay. Your office can then inform the patient. Good billing departments can get most claims through to the major payers in less than two weeks.
Overall, the billing department is part of your team. They need to be on-board with your requests and policies. If you find there is a lack in this area, it's time to set up a meeting and set some standards for them. You are their customer and should be treated as such.

Article By P.j. Cloud-moulds of Physicians Practice

The Unknown Impact of Health Reform on My Private Practice: An Honest Opinion From a Real Physician... "I honestly don't know."

By Melissa Young, MD, Courtesy of Physicians Practice

Patients have been asking me for the last few months, "So what do you think is going to happen to your practice with Obamacare?"  I told them what I assume most physicians are thinking, "I really don’t know. I’m apprehensive. But I guess I’ll find out."

There’s been talk about physicians being inundated with new patients because there will be an increase in demand for physicians without increasing the supply. In our case, we already have such a backlog, I don’t know what we’ll do if more patients call to make new patient appointments. I am concerned that we are going to have to close to new patients for a while if the wait for a new patient appointment gets any longer. As it is, patients are very dissatisfied with the wait. I can’t begin to imagine how primary-care physicians will handle this.

There is also the concern about increasing patient financial responsibility. That will put a greater strain on the patients, as well as on our staff who will have to collect more from patients. As many patients don’t understand when they have deductibles or how much their copays are, if their portion of the bill increases, it may become increasing difficult to get paid for services.

As a business owner and employer, there is also the question of providing health insurance to employees. We are a small enough practice that, as I understand it, I am not legally obligated to provide insurance coverage for the employees, but I have always done that anyway. I think it helps keep employees happy and instills some loyalty to the practice. Having said that, I was still obligated to print out and complete a form that I had to distribute to each employee, stating who is eligible for insurance, that we offer it, and that it is deemed affordable. They actually found it somewhat amusing that I had to inform them of something they already knew. Sigh. To think trees had to die for this paperwork.

So, what do I think will happen? Will Obamacare have a significant impact on the way our practice is run now? I honestly don’t know. But I guess I’ll find out.

Article Courtesy of:

Six ICD-10 Questions for Your Medical Claims Clearinghouse

By Lucien W. Roberts courtesy of Physicians Practice

It's September, and you've been busy since February preparing for ICD-10. No? Well, fortunately you still have 12 months to get ready. One key partner in your preparations should be your medical claims clearinghouse.

One of the things I learned from the HIPAA 5010 transition was that it hurt cash flow in way too many practices. I had the chance to observe two practices that had the same practice management system, the same payers, but different clearinghouses. One practice was a month down on cash flow well into the spring; the other had no cash flow disruption at all.

A very few clearinghouses made the 5010 transition seamless for practices; accepting both 4010- and 5010-formatted claims and then converting them, as necessary, on a payer-by-payer basis.  I never appreciated the value of a reliable clearinghouse partner until the 5010 transition.

So how does that lesson apply to the ICD-10 transition? As with 5010, your practice's cash flow will be at risk during the ICD-10 transition. Here are six questions to ask your clearinghouse as you prepare your practice for ICD-10.

1. Our practice suffered a disruption of cash flow during the 5010 transition. What will you do differently with ICD-10 to prevent a repeat performance?

(This is an optional question for practices that suffered during the 5010 transition. If you do not like the answer you get, consider moving to a clearinghouse whose 5010 performance was stronger.)

2. Would you please run a report of claims rejections and denials by ICD-9 code?

(And while you're at it, please provide guidance on how to prevent these errors.)

3. Would you run a similar report by payer?

(Such a report will give you a good basis for meeting with your key payers and discussing their ICD-10 conversion plans.)

4. Please run a report that identifies the "generic" codes each provider uses regularly.

(Generic ICD-9 codes (like 250.00 for Type II diabetes) are most likely to be denied by payers going forward. These codes should be your first priority as you commence ICD-9 to ICD-10 mapping.)

5. Could you share advice on mapping my superbill from ICD-9 to ICD-10?

(Coding remains each provider's responsibility. However, your clearinghouse may be helpful in this critical exercise.)

6. Could you share the progress of your discussions with my practice management vendor and my payers? When can we start sending test claims?

(Mapping from ICD-9 to ICD-10 is not an exact code-for-code proposition. Prudent practices will map — test — refine — test — refine their coding well before they submit their first real ICD-10 claim on Oct. 1, 2014.)

Post ICD-10 performance evaluation

TK Software of Carmel, Ind., is one clearinghouse whose clients were unaffected by the 5010 transition. TK Software's managing partner, Matt Behringer, shared their post-ICD-10 plans: "A post ICD-10 performance evaluation is critical," Behringer says. "Your clearinghouse should be able to create reports that show encounters, dollars billed, dollars rejected, and/or denied [claims] per day for each provider, pre- and post-ICD-10."

I agree. Ongoing cash flow in an ICD-10 world will require diligence and corrective education in the days and months following Oct. 1, 2014. A reliable clearinghouse partner helps, but it remains incumbent upon practices to begin their ICD-10 preparations now.

Article by: Lucien W. Roberts, III, MHA, FACMPE, is a consultant and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at

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How Health Reform Is Changing How Physicians Care For Female Patients

Health reform is bringing about massive changes: from shifting reimbursement, to increasing emphasis on health IT, to new models of care.

It's also beginning to change the way female patients interact with physicians, the services female patients request from physicians, and the services physicians might want to consider recommending to their female patients.

"Generally it takes a little bit of time for the general public to really start to use any sort of implementations of a new law," Lauren Fifield, senior health policy advisor at Practice Fusion, recently told Physicians Practice. "With health reform, there are a handful of things that have already come into effect, and I think that those are only going to become more and more applicable to physician offices."

One of the biggest changes physician offices might encounter with female patients is increasing demand for preventive services, said Fifield, adding that insurers must now make certain preventive services available to women without a copayment or co-insurance.

Some of the most recently added preventive services to fall into this category include:
  •  Well-woman visits
  • Gestational diabetes screening for women 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes.
  • Domestic and interpersonal violence screening and counseling for all women.
  • Breastfeeding counseling from trained providers; access to breastfeeding supplies.
  • Contraceptive services and counseling.
Of note for physicians: Many of these services include an element of counseling, said Fifield. "These are all sort of really focused on not just, let's give a patient a medication or make sure they have a mammogram, but ... making sure that they are treating the patient more holistically."

Physicians may also experience higher demand from female patients in general moving into 2014, and they may encounter more female patients with undiagnosed chronic conditions or conditions that have gone untreated for a long period of time. That's because more female patients will become newly insured in 2014 due to the health law.

"I think providers will start to have higher volumes of patients and also have to really work as a care team ... to manage the care of women that are going to be sort of entering the healthcare space newly with their new insurance," said Fifield.

So how should physicians prepare for these changes?

Ensure key individuals in your practice are aware of the preventive services that are available without cost to patients. That way they can inform patients of these services during visits.

In addition, pay close attention to the counseling elements associated with these preventive services and ensure your practice is prepared to incorporate that into its work flows, said Fifield.

"I also think that really utilizing technology will be incredibly helpful," she said. "Technology for doctors to help make scheduling more efficient, to make visits more efficient since they may be dealing with higher volumes of patients, and an [EHR] or other tools that help a care team manage their patients and sort of coordinate that care will be important." 

Article By Aubrey Westgate of Physician Practice

Monday, October 7, 2013

How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him here.

Article By G. John Verhovshek, MA, CPC