Wednesday, March 19, 2014

Health Insurance Exchange Confusion Hinders Patient Sign Ups

HHS Secretary Kathleen Sebelius testified before the House Ways and Means Committee on March 12 that there will be no more tweaking in the of the individual mandates under the Affordable Care Act (ACA).  This after the White House announced the extension of exemptions on the basis of hardship.

A list of those hardships, reported by the Wall Street Journal, includes more than a dozen ways that Americans could qualify, including homelessness, having utilities shut off, and having a very low income in a state that did not expand its Medicaid program. Sebelius also refused to say whether the White House goal of signing up 7 million people will be met by the March 31 deadline, when open enrollment ends. Thus, the deadline for open enrollment will not be extended, according to Sebelius, despite lack of any clear data on the number of people who have both signed up and actually paid their premium. Individuals without coverage by the deadline will face a penalty at tax time, which will likely be deducted from any anticipated tax refund next year. Any way you look at it, the hope of the White House that individuals will actually buy into the private purchase of health plans seems largely misplaced.  A great deal of the problem lies in the confusing array of plans that can be purchased through the exchanges. First, a purchaser must figure out what is being offered. Often termed “metal” plans: bronze, silver, gold and platinum, one would seemingly need to possess an advanced college degree simply to understand the choices.  The lower-premium plans, are the “bronze" plans, which carry higher initial copayment responsibilities.  This may at first seem attractive to a lower wage earner.  However, such a plan would actually benefit a higher-income individual, who could afford the 40 percent copayment.  The platinum plan, which costs more in premiums but carries a 10 percent initial copayment, would seem to be better suited to a person who lacks resources to pay nearly half of his initial healthcare expense from his own savings.  Recognizing the problem faced by lower wage earners, there are three alternative silver plans for lower income earners, which the website Obamacare 411 explains as follows:  “These three alternative health insurance plan options are only available for people that have the lower incomes.  The three health insurance plans have lower out-of-pocket expenses for people that are enrolled in the health insurance plan.  Basically, what this all means is that even though you are buying a silver tier plan; you are actually being given a better health insurance plan.
  • 100 percent to150 percent of the federal poverty level (FPL) = 94 percent AV, better than average platinum plan
  • 150 percent to 200 percent of FPL = 87 percent AV, better than average gold plan
  • 200 percent to 250 percent of FPL = 73 percent AV, better than average silver plan
If you have difficulty following this, you see my point.  One thing people do universally seem to understand:  “What is this going to cost me?”  The answer should open more than a few eyes: All plans cap out of pocket expenses at about $6,350 for an individual, and $12,700 for a family in 2014. This means for an individual in good health, who must pay for coverage without a subsidy, the annual out of pocket expense could be well over $14,000, even with the least expensive plan.  The next question on a consumer’s mind will likely be: “What happens if I just give up and hope I don’t get sick?”  Naturally, without insurance the same individual would be liable for the entire cost of any unexpected care. But Americans have proven more than willing to accept this risk.  If a person does not choose to comply with the individual mandate before the March 31 deadline, he will face a tax bill of between $95 and $285, if I understand the rules and exemptions correctly. Finally, the largest problem facing the White House is the Republican message: “Vote against Democrats, and this all goes away.” It doesn’t, but explaining that, would be complicated.

Article  By Martin Merritt from Physicians Practice

Medical Practices Struggle to Collect Payments Due to New Payer Tactics

Over the past month or so, we've seen so many side effects from insurance companies both opting in to provide insurance through the health insurance exchanges and opting out.  Those that opted in are losing a lot of money right now due to the low number of enrollees.  Those that opted out are also losing a lot of money because they lost several of their clients when they dropped them from enrollment. 

Here's how those side effects are trickling down to medical practices: 1. Insurance companies that typically paid you within 15 days to 20 days are now holding onto that money and making more money in interest on it, leaving your cash flow suffering.  I'm also finding that they you are not paying until you call asking where that money is. 2. Insurance companies are dropping claims stating, “We never received those dates” when the two dates before and the two dates after, all within the same batch, have been paid.  This is resulting in your billing department having to follow up on all claims older than 30 days. 3. Insurance companies are creating narrow networks and patients are having difficulty finding in-network providers.  This means that many of your patients may have to pay out of network rates.  They not only have high deductibles, they also have high premiums. 4. Insurance companies are hiring outsourced auditors to review every single claim they have paid you.  If they find one error, they're coming after that money.  I once had to write a refund check for 4 cents.  Yes, 4 cents.  This can be devastating to your bank account. Essentially, these changes mean that your practice will be more and more strapped for basic cash flow.  Payroll, expenses, administrative time chasing this money down, are all a drain to your business.   Your businesses accounts receivable should be considered an asset until it starts costing your more to obtain that money than you are paid for that claim.  Here are some tips you can implement right now to help you get through this new “norm.” 1. Be sure your billing staff is calling on claims older than 30 days to 45 days if you are typically paid sooner. 2. Your billing department should have access to your clearinghouse website and be able to prove that all claims were sent on time. 3. Start keeping a list of alpha-prefixes or some type of identifier that shows it's a newer plan and you are perhaps not in network. When calling and verifying, do not assume you are in network.  Ask the rep: “Are we in network with this plan?” and if you are not, ask for out of network benefits.  I'm also seeing that many specialties are not a plan benefit, so even if you are in network, your specialty may not be covered.  In this case, you will need to turn the patient into a cash paying patient. 
Keep your eye on your accounts receivable and your bank account.  It is imperative that you own this area of your business in this volatile insurance fiasco.

Article By  from Physicians Practice

DMEPOS Fee Schedule - 2014 April Update Medicare/Noridian

DMEPOS Fee Schedule - 2014 April Update

MLN Matters® Number: MM8645
Related Change Request (CR) #: CR 8645
Related CR Release Date: March 11, 2014
Effective Date: April 1, 2014
Related CR Transmittal #: R2902CP
Implementation: April 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Part A/B Medicare Administrative Contractors (MACs), Hospice and Home Health (HHHMACs), and Durable Medical Equipment MACs (DME MACs) for DMEPOS items or services paid under the DMEPOS fee schedule.

Provider Action Needed 
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8645 that alerts providers and suppliers that CMS issued instructions updating the DMEPOS fee schedule payment amounts. Be sure your billing personnel are aware of these changes.

CMS updates DMEPOS fee schedules on a quarterly basis, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. The quarterly update process for the DMEPOS fee schedule is located in the "Medicare Claims Processing Manual", Chapter 23, Section 60, which is available at This link will take you to an external website. on the CMS website.

Key Points of CR8645

Splints, Casts and Certain Intraocular Lenses (IOLs) 
The following are the HCPCS codes for splints, casts, and certain IOLs added to the DMEPOS fee schedule file:
  • A4565, Q4001, Q4002, Q4003, Q4004, Q4005, Q4006, Q4007, Q4008, Q4009, Q4010, Q4011, Q4012, Q4013, Q4014, Q4015, Q4016, Q4017, Q4018, Q4019, Q4020, Q4021, Q4022, Q4023, Q4024, Q4025, Q4026, Q4027, Q4028, Q4029, Q4030, Q4031, Q4032, Q4033, Q4034, Q4035, Q4036, Q4037, Q4038, Q4039, Q4040, Q4041, Q4042, Q4043, Q4044, Q4045, Q4046, Q4047, Q4048, Q4049, V2630, V2631, V2632.
As written in the MLN Matters® Article MM8523 (Change to the Reasonable Charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses) at This link will take you to an external website., for dates of service on or after April 1, 2014, payment for splints, casts and IOLs inserted in a physician's office will be made using national fee schedule amounts.
For splints and casts, codes A4565 and Q4001-Q4049 are used when supplies are indicated for cast and splint purposes and:
  • Payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast. Per the regulations at 42 CFR Section 414.106, national fee schedule amounts for 2014 for these items were developed using 2013 reasonable charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June 2013, which is 1.8 percent; and 
  • For each year subsequent to 2014, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment as described in Section 1886(b)(3)(B)(xi)(II) of the Social Security Act.
For intraocular lenses (codes V2630, V2631 and V2632), payment under the DMEPOS fee schedule is only made for lenses implanted in a physician's office:
  • For payment of IOLs inserted in a physician's office furnished from April 1, 2014, through December 31, 2014, regulations at 42 CFR Section 414.108 require national fee schedules be established based on the Calendar Year (CY) 2012 national average allowed charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 24-month period ending with June 2013, which is 3.5 percent;
  • For each year subsequent to 2014, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, adjusted by the productivity adjustment as described in Section 1886(b)(3)(B)(xi)(II) of the Act; and 
  • For IOL codes V2630 and V2631, national fee schedules amounts have been established using the fee schedule amounts for comparable code V2632 since there is insufficient allowed charge data for use in calculating the fee schedule amounts.
Subject to coinsurance and deductible rules, Medicare payment for these items is to be equal to the lower of the actual charge for the item or the amount determined under the applicable fee schedule payment methodology.
Payment Category Reclassification of Certain DME  
Effective for dates of service on or after April 1, 2014, certain HCPCS codes for DME are reclassified from the payment category for inexpensive or other routinely purchased DME to the payment category for capped rental items, to align with the regulatory definition of routinely purchased equipment found at 42 CFR Section 414.220(a)(2).
These changes were determined through rulemaking (CMS-1526-F) and as written in the MLN Matters® Article MM8566 titled Rescind/Replace Reclassification of Certain Durable Medical Equipment from the Inexpensive and Routinely Purchased Payment Category to the Capped Rental Payment Category, available at MLN/MLNMattersArticles/Downloads/MM8566.pdf This link will take you to an external website. on the CMS website.
As part of the April 2014 update to the DMEPOS fee schedule, the methodology used to calculate fee schedule amounts for capped rental items has been used to establish new fee schedule amounts for the following HCPCS codes:
  • A4639, A7025, E0117, E0144, E0198, E0300, E0620, E0656, E0657, E0740, E0762, E0764, E0849, E0855, E0856, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1014, E1029, E1030, E1161, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1700, E2227, E2310, E2311, E2312, E2313, E2321, E2322, E2325, E2326, E2327, E2328, E2329, E2330, E2351, E2373, E2374, E2376, E2377, E2378, E2500, E2502, E2504, E2506, E2508, E2510, K0607, K0730.
Consistent with the capped rental payment methodology, only Rental Amounts (RR) will appear on the fee schedule file for the above codes, effective April 1, 2014, and:
  • The HCPCS codes transitioning to the capped rental payment category with corresponding KC, KF or KE modifiers will continue to have rental amounts associated with these modifiers on the fee schedule file;
  • The capped rental fee schedule amount is calculated based on ten percent of the base year purchase price increased by the covered item update; 
  • This is the fee schedule amount for rental months one through three. Beginning with the fourth month, the fee schedule amount is equal to 75 percent of the fee schedule amount paid in each of the first three rental months; and
  • All of the payment rules for capped rental items, including guidelines regarding continuous use and transfer of title to the beneficiary following 13 months of continuous use, apply to these codes, effective for claims with dates of service on or after April 1, 2014.
Also effective April 1, 2014, MACs will process and pay claims for capped rental wheelchair accessories on a lump sum purchase basis when used with complex rehabilitative power wheelchairs (wheelchair base codes K0835 – K0864). In this case, the supplier must give the beneficiary the option of purchasing these accessories at the time they are furnished. The purchase fee schedule amount for capped rental accessories furnished in this manner is equal to the rental fee (for months one through three) multiplied by ten. If the beneficiary declines the purchase option, the supplier must furnish the accessory on a rental basis and payment will be made in accordance with the capped rental payment rules.
Specific Coding and Pricing Issues
As part of this update, effective April 1, 2014, HCPCS code L8680 is not included on the 2014 DMEPOS fee schedule file and the coverage indicator is revised to "I" to show it is not payable by Medicare. Note that:
  • For neurostimulator devices, HCPCS code L8680 is no longer separately billable for Medicare because payment for electrodes has been incorporated in CPT code 63650 Percutaneous implantation of neurostimulator electrode array, epidural. 
  • CMS established non-facility practice expense inputs for CPT code 63650 in the Medicare Physician Fee Schedule Final Rule (published November 27, 2013). As a result, practitioners should not report electrode(s) using code L8680 in conjunction with a lead implantation procedure furnished in any setting for Medicare.  
  • Also, this change for code L8680 will be available on the HCPCS Quarterly Update website at This link will take you to an external website. on the CMS website.
Additional Information
The official instruction, CR8645, issued to your MAC regarding this change is available at This link will take you to an external website. on the CMS website.
Last Updated Mar 14, 2014

Vitamin B 12 Injection LCD Retirement - Effective March 7, 2014 Medicare/Noridian

Vitamin B 12 Injection LCD Retirement - Effective March 7, 2014

The following Local Coverage Determination (LCD) has been revised under contractor numbers 01111 (California), 01211 (Hawaii and Territories), 01311 (Nevada), 01911 (Former NO-CA, HI and Territories).

Medicare Coverage Database (MCD) Number/Contractor Determination Number: L33502
Policy Name: Vitamin B 12 Injection
Effective Date: 03/07/2014

NOTE: LCDs are retired due to lack of evidence of current need(s) for the education and/or edits or in some cases because the material is addressed by a National Coverage Determination (NCD), a coverage provision in a CMS interpretative manual, another LCD or an article.  Retirement does not mean that medical necessity has changed or that the LCD no longer reflects appropriate criteria. The guidance in the retired LCD may be helpful in assessing medical necessity.
To access the Noridian Retired LCDs from our website, follow the instructions below.
  • Go to
    • The End User Agreement for Providers will appear if you have not recently visited the website. Select "Accept" (if necessary).
  • Select the state/contract of interest. This link will redirect you to the state specific listing of retired LCDs on the CMS MCD.
Last Updated Mar 14, 2014

Wednesday, March 12, 2014

The Disturbing Confessions of a Medical Scribe
 Article Courtesy of

The disturbing confessions of a medical scribe

As a medical scribe working with a large, well-known scribe company, unnamed to protect my job, it makes me proud reading all the articles published about how much having a scribe benefits a physician, especially in the emergency department. I enjoy my job immensely and I am grateful for the opportunity to learn and engage in patient care. However, as a pre-medical student working next to several other doctor-hopefuls in a high stress environment, being a scribe frustrates me on an ethical level.
Let’s examine the structure and reasoning that has made medical scribe programs so successful. When EMR systems were first introduced, there was resistance, but it gave way to the push for efficiency. The biggest benefit of EMRs is easy: risk management. By allowing for documentation of every little part of a patient’s care, EMRs significantly decrease the risk of mistakes slipping through the cracks. It allows for better defense of the physician’s medical decisions, even months down the line.
For example, a physician I worked with was asked to go to court for a patient who had been assaulted by her boyfriend. The patient had been seen several months ago in the ED. Few physicians would be able to remember all the details of an encounter so long ago. His testimony was therefore entirely based on the medical chart, written by me and approved by him. The EMR allowed for comprehensive, detailed documentation of test results, discussions with the patient, and interactions with the police.
Unfortunately, such comprehensive medical records take time and effort to write. Physicians complain that they were becoming little more than data entry specialists, dedicating large portions of the time they should be spending with patients to clicking buttons. In comes the scribe. Usually students or recent graduates interested in becoming a medical provider, we become the physician’s right hand. Scribes are purported to decrease physician burnout considerably and increase ED efficiency. Better documentation also leads to better billing, so hospitals make more money. The physicians I work with, in a hospital who has been using scribes for over 3 years now, have all been grateful for the program.
Sounds great, right? The winning combination of EMRs and scribes. The road to increased efficiency, increased Press-Ganey scores, increased billing accuracy, increased fraud, increased profits for the administration. Happiness abounds.
How many of you missed the “increased fraud”?
Medical billing is based off charting and documentation, and that can have different levels. Level 5 charts are billed the most, when the provider offers the higher level of care. Ideally, EMRs make documentation more accurate, allowing for more level 5 charts for medical coding and billing. But when all it takes is a few buttons to increase your billing, how many physicians submit to small temptations and conveniences?
In Epic’s CareConnect, a widely used EMR, there is a small button that, when pushed, indicates the physician has counseled the patient to stop smoking. It adds a small amount ($20-30) to the billing, and the physician makes a little more.
I’ve been told by physicians, “If the patient is an active smoker, just click that button about the counseling.” Most of the time, the patient is counseled. Sometimes though, they aren’t. But if that button isn’t pressed, eventually, it comes back onto me.
“I told you to press it, so just press it.” At which point, I protest, “But you didn’t counsel them.”
The physician responds, “You probably just weren’t paying attention.” Or “It’s okay, just click it anyways.” As a “good” scribe, I don’t say anything and I click the button.
Similarly, physicians can make “macros” which auto populate certain parts of the chart, such as the physical exam. It’s nice and saves time, and it is usually accurate. It ensures that there are enough areas input for the physical exam for the chart to be level 5. But sometimes, the physicians don’t do everything their macro says they’ve done. In those cases, I go in and take out the inaccurate information. Sometimes, I’m told to just leave it, that I must have missed when they did it.
How do I know it’s not me? Because as the physician’s right hand, I have been with them the entire shift, even during any breaks they take. I have paid incredibly close attention to everything they say or do so my charts are as complete as possible. That’s my job. I know they did not counsel the patient. I know they did not ask for social history. I know they did not listen to the patient’s heart rhythm or breath sounds. I know every time I “just leave it,” I am lying in a medical document.
I don’t blame the physicians. The pressure on physicians from the administration is incredible. If a physician only charts what they has done, that means their charts sometimes don’t reach level 4 or 5. When that happens too often, administration comes down, and they’re told to write better charts. They lose money when their charts get down coded.
So what do they do? They click a few extra buttons for that higher level chart, because they’re seeing so many patients in a shift and it’s that much easier to just click a few buttons than double the time in a patient’s room when there are other acute patients waiting. Considering how much debt physicians are straddled with as a result of the insane cost of medical education, it’s clear why that extra $20 per patient counseled is so easy.
These are small, tiny transgressions. In the grand scheme of things, it probably does not matter that that the patient did not actually get counseled about smoking cessation. But small things add up and in the end, the burden of all this comes back onto the patient. More importantly, if thousands of small lies are okay and never brought to light, how many bigger lies are out there, hidden by convoluted billing, poor memories, and a healthcare system that lacks any semblance of transparency?
I will never regret being a scribe — as I prepare to apply to medical school, I know my experience as a scribe will be a core piece of my application. I am lucky to have this opportunity. I am also a person with bills to pay, and I don’t want to lose my job. As a “good” scribe, I understand that the chart I am writing is ultimately a reflection of the physician, and therefore at the end of the day, I will write whatever the physician wants me to write. It isn’t my job to say no. Whether or not it’s my responsibility to is undecided.

The author is an anonymous medical scribe.

Cerumen Removal - CPT 69210 Noridian/Medicare

Cerumen Removal - CPT 69210

Effective in 2014, the American Medical Association (AMA) CPT manual identifies CPT code 69210 (removal impacted cerumen requiring instrumentation, unilateral) as a unilateral procedure. CMS has determined that, regardless of unilateral or bilateral, 69210 will remain bilateral and will allow only one unit per date of service billed. Appending modifier 50 is not acceptable.
The work Relative Value Unit (RVU) was maintained at 0.61.

For further details, consult the Federal Register/Volume 78, No. 237 / Tuesday, December 10, 2013/Rules and Regulations 74341(14) Cerumen Removal (69210) at This link will take you to an external website..
Last Updated Mar 07, 2014

ICD-10 Limited End to End Testing with Submitters Noridian/Medicare

ICD-10 Limited End to End Testing with Submitters

MLN Matters® Number: MM8602
Related CR Release Date: February 21, 2014
Related CR Transmittal #: R1352OTN
Related Change Request (CR) #: CR8602
Effective Date: July 7, 2014
Implementation Date: July 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to Medicare Claims Administration Contractors (Durable Medical Equipment Medicare Administrative Contractors (DME MACs), A/B Medicare Administrative Contractors (A/B MACs), and/or Home Health and Hospices (HH & H MACs) for services provided to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8602 which instructs providers and clearinghouses on how to volunteer to be chosen for ICD-10 End to End testing with Medicare in July 2014. Potential testers must complete the volunteer form on the MAC website by March 24, 2014.

The International Classification of Disease, Tenth Revision, (ICD-10) must be implemented by October 1, 2014. While system changes to implement this project have been completed and tested in previous releases, the industry has requested the opportunity to test with the Centers for Medicare & Medicaid Services (CMS).
Change Request (CR) 8602 will allow for a small subset of Medicare claims submitters to test with MACs and the Common Electronic Data Interchange (CEDI) contractor to demonstrate that CMS systems are ready for the ICD-10 implementation. This additional testing effort will further ensure a successful transition to ICD-10.
To facilitate this testing, CR8602 requires MACs to do the following:
  • Conduct a limited end to end testing with submitters in July 2014. Test claims will be submitted July 21-25, 2014.
  • Each MAC (and CEDI with assistance from DME MACs) will select 32 submitters to participate in the end-to-end testing. The Railroad Retirement Board (RRB) contractor will select 16 submitters.) Testers will be selected randomly from a list of volunteers. At least five, but not more than ten of the testers will be a clearinghouse, and submitters should be a mix of provider types.
  • By March 7, 2014, the MACs and CEDI will post a volunteer form to their website to collect volunteer information with which to select volunteers. The form will provide information to verify that volunteers are ready to test, meet the requirements to test, and collect needed data about the tester (how they submit claims, what type of claims will be tested, etc.). Volunteers must submit the completed forms to the MACs and CEDI by March 24, 2014.
  • By April 14, 2014, the MACs and CEDI (for the DME MACs) will notify the volunteers that they have been selected to test and provide them with the information needed for the testing, such as:
    • How to submit test claims (for example, what test indicators should be set);
    • What dates of service may be used for testing;
    • How many claims may be submitted for testing (Test claims volume is limited to a total of 50 claims for the entire testing week, submitted in no more than three files);
    • Request for National Provider Identifiers (NPIs) and Health Insurance Claim Numbers (HICNs) that will be used in testing (no more than 5 NPIs and 10 HICNs per submitter);
    • Notice that if more than 50 claims are submitted, they may not be processed;
    • Notice that claims submitted with NPIs or HICNs not previously submitted for testing, likely will not be completed; and
    • Notice of potential Protected Health Information (PHI) on test remittances not submitted (and instructions to report PHI found to the MAC).
    • MACs and CEDI (for the DME MACs) will collect information from the selected test volunteers to request the HICNs, NPIs, and Provider Transaction Access Numbers (PTANs) the testers will use during the testing. The forms for this information must be completed and returned to the MAC/CEDI by May 2, 2014. If these forms are not returned by May 2, the tester may lose the opportunity to test.
    • CEDI will instruct suppliers to submit claims with ICD-10 codes with Dates of Service (DOS) 10/1/2014 through 10/15/2014. They may also submit claims with ICD-9 codes with DOS before 10/1/2014.
    • MACs will instruct testers to submit test claims with ICD-10 codes with DOS on or after 10/1/2014. They may also submit test claims with ICD-9 codes with DOS before 10/1/2014.
    • MACs and CEDI will be prepared to support increased call volume from testers during the testing window, and up to 2 weeks following the receipt of the Electronic Remittance Advices (ERAs) from testing. MACs and CEDI will provide information to the testers on who to contact for testing questions. There may be separate contacts for front end questions and remittance questions.
    • MACs will post an announcement about the testing to their websites.
Additional Information
The official instruction, CR 8602, issued to your MAC regarding this change may be viewed at This link will take you to an external website. on the CMS website.
Last Updated Mar 10, 2014

Tuesday, March 11, 2014

Physicians Should Prepare Now for Medicare Cuts

By David Doyle from Physicians Practice

Roughly 27 percent of Americans on Medicare are enrolled in a Medicare Advantage plan. Federal funding for this Medicare alternative has already been cut by 6.5 percent this year, and additional cuts are planned. Preliminary 2015 rates for Medicare Advantage will be announced in February and finalized in April.

Hospitals are responding to existing and upcoming Medicare cuts by trimming staff. Lawrence + Memorial Hospital in New London, Conn., reduced its workforce by 33 positions in September 2013. In its press release, the hospital specifically blamed a predicted “$260 billion reduction in Medicare outlays between 2013 and 2022.” Other hospitals are also cutting staff and will continue to do so if Medicare cuts become too cumbersome — bad news for the thousands of doctors who recently sold their practices to healthcare systems.

Cuts to Medicare reimbursement rates and Medicare Advantage are impacting private practices as well. Last November the nation’s largest provider of Medicare Advantage Plans, UnitedHealth Group, sent termination letters to physicians in 10 states. According to an article in The Wall Street Journal, these letters cited “significant changes and pressures in the health care environment.” UnitedHealth Group hopes to trim the program to between 85 and 90 percent of its current size by the end of 2014.

These sudden, drastic cuts threaten patient care and will even force many patients to stop visiting specific physicians midtreatment. However, some practices are fighting back. Judge Stefan R. Underhill, the United States District Judge for the District of Connecticut, issued a temporary injunction in December that prohibits UnitedHealth Group’s planned dismissals in Fairfield and Hartford Counties. Another lawsuit in the state of New York is still pending. The American Medical Association even weighed in when it recently joined with 30 medical associations and physician advocacy groups to oppose “wide-spread terminations in the Medicare Advantage program.”

Additional debates over the future of Medicare cuts will likely ensue over the next few months, but what can practices do in the meantime?

As cuts to Medicare and Medicare Advantage reimbursement rates go into effect, practices that serve Medicare patients must ensure that it’s still profitable for them to do so.

Begin by calculating the amount of time a physician can spend with a Medicare patient before the practice loses money. Next, consult your patient records from the last three months to determine whether physicians are exceeding this mark. If the practice loses money every time it sees a Medicare patient, you must set a strict time limit for physician consultations and monitor any changes over the next three months. If at the end of this time you discover that treating Medicare patients is still a net loss for the practice, then it might be time to reconsider your patient base.

Practices that are removed from Medicare Advantage networks will also need to adjust. If your practice is one of these, and you haven’t already done so, you must inform your affected patients as soon as possible. According to The Washington Post, many patients don’t understand that these terminations were not their physicians’ fault. Help your patients by either referring them to physicians within their network whom you trust, or recommending alternative Medicare Advantage networks that your practice still belongs to.

Taking precautionary measure now will help protect your practice’s long-term viability and reputation without leaving your patients out in the cold.

Courtesy of Physicians Practice

Simple Proof that EHR and Meaningful Use are Burdens: A Physican's Point of View

By Daniel Essin, MA, MD from Physicians Practice

The editors of the Journal of the American Medical Association (JAMA) and the BMJ (formerly British Medical Journal) have been proponents of evidence-based medicine (EBM) for some time. Over the years, they have become friendly with the "pioneers" in the field and recently got them together for a retrospective. The video from JAMA and the editorial from BMJ are worthy of your attention. I must admit, that to someone equipped with a scientific frame of mind and a healthy dose of skepticism, it always surprised me that what the EBM people were promoting wasn't the norm.

If there is one thread that unites my approach to EHR it is: Show me the evidence that it is safe, effective (does what you expect and produces beneficial results), and worth the time and money that are devoted to it. Also, what is the opportunity cost? What else could have been done differently or better if not consumed with trying to conquer an EHR. Frankly, and despite our fervent hopes regarding benefits that seem obvious, there is darn little solid evidence as even the people at RAND who make glowing predictions in 2005 were forced to admit [Arthur L. Kellermann and Spencer S. Jones, "What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology," Health Affairs, 32, no.1 (2013):63-68]. Let's look at some evidence related to burden. Wiktionary defines burden as a.) A heavy load; b.) An onus; and/or c.) A cause of worry; that which is grievous, wearisome, or oppressive. Given the definition, one could stop here. EHR is a burden. If it's a burden that is all the more reason that there should be evidence of effectiveness before the burden is imposed. Now let's look at what the government has to say about other burdens, specifically those relating to paperwork. An EHR is intended to be an electronic substitute for paper so, logically, the Paperwork Act and its requirements should apply to any EHR regulation. The Electronic Code of Federal Regulations, Title 5, Part 1320 — Controlling Paperwork Burdens on the Public, §1320.1 says: "The purpose of this part is ... to reduce, minimize, and control burdens and maximize the practical utility and public benefit of the information created, collected, disclosed, maintained, used, shared, and disseminated by or for the Federal government." There is plenty of anecdotal evidence that EHRs promote inefficiency, slow the flow of patients, and cost billions. This can hardly be called "utility." In case you're wondering, I am more willing to accept anecdotal evidence of problems that I am of "success" for one primary reason. In both cases people are straining to make the EHR "work." A success in the face of extraordinary effort cannot simply be attributed to the EHR itself for it was not working to start with, hence the need for extra effort. Failure and dissatisfaction also occur in the face of this same effort, only in these cases, heroic life-sustaining interventions were not enough. The EHR itself was so fraught with problems that even superhuman efforts could not overcome them. So much for utility. How about public benefit? Well ... the claims that EHR and the meaningful use exercise will benefit the public are just that — claims;  a hypothesis. The government is conducting a Phase III clinical trial of a medical modality without going through Phase I and Phase II. It's a crapshoot but maybe it will succeed. The problem is, there is no study design, no protocol, no tracking of things other than attestation and meaningful use reports. Any claim of success will remain as unsupported by evidence as it is now. The requirements under the Affordable Care Act give every evidence of being a burden. They give little conclusive evidence of benefit. There are few criteria for what would constitute success. What is the evidence for that? Chest Physician [vol. 9, no. 1, January 2014] reported that the "earliest that physicians will progress to Stage 3 of the meaningful use requirements will be in January 2017. Officials at CMS are still developing the Stage 3 requirements and expect to issue a proposed rule sometime in the fall of 2014." So, no clear utility and no clear benefit yet an onus and a cause of worry. It certainly violates the spirit, if not the letter, of the Paperwork Reduction Act. If it walks like a burden and talks like a burden, it's a burden.

 Courtesy of Physicians Practice:

Common Errors on CMS-1500 (Version 02/12) Claim Form: Implementation Date 04/01/2014

Helpful Hints to Improve Claim Processing
  • Use a Legible Font – Use a size 10 or 12 font in Courier New style, making sure information is properly aligned on the form.
  • Remove all Staples – Remove all staples, paper clips, or binder clips from claims and attachments. These items may prevent the scanner from properly imaging the claim and corresponding attachments as well as slow down their processing.
  • Remove all Sticky Notes and Stickers – Sticky notes and stickers are often used to convey additional information but often cover information needed for the processing of the claim resulting in additional processing time. Avoid using sticky notes and stickers. Any additional information about the claim should be included on an attachment.
  • Don’t Highlight Information – Although highlighting information is intended to make elements on a claim stand out, it has the reverse affect. When scanned, this information cannot be processed as it appears to be blacked out. Do not use highlighters on paper claims.
  • Refrain from Extraneous Information – Extraneous information on the claim adds additional time to the processing of a claim. Extraneous information can include but is not limited to: descriptions after a diagnosis code, descriptions after a procedure code, any stamped information such as “Corrected Claim” in Item 24, addresses in the margins around the claim form, circling information or using an arrow to indicate important information. 
  • Use the Correct Mailing Address – Using the address that is appropriate for the claim will assist in timely processing. Mailing the claim to the incorrect address can cause delays in processing or possible denials. If Part B, DME, and/or Part A claims need to be submitted, do not submit them in the same envelope. Include only one type of claim per envelope.
View the “CMS-1500 Form Version 02/12 Completion Tips” webpage at for Item visuals and completion details about the following.
  • Item 17 – Name of Referring Provider or Other Source
  • Item 21 – Diagnosis or Nature of Illness or Injury
  • Item 24E – Diagnosis Pointer
Courtesy of Noridian

How to Implement Open Access Scheduling at Your Medical Practice

By Carol Stryker from Physicians Practice

It may be time for your medical practice to implement open access, also referred to as advanced access or same day scheduling. It certainly deserves serious consideration.
Here's how open access scheduling works, and why your practice may want to consider it. Defining open access
Open access covers a variety of scheduling approaches, including completely unscheduled (a la an ED or urgent care center), open blocks of time on certain days, and a specific number of appointments kept open in each clinic session.  A practice could utilize more than one of these options, as well as traditionally scheduled appointments.  The imperative is to do what makes sense for the patients and the providers.
 For instance, it might make sense for an OB to block out Tuesday mornings for first and second trimester appointments and let patients come in at their convenience for these typically quick appointments. The methodology could also support scheduled group meetings at the beginning or end of the open access period to disseminate general information and answer typical questions. Another alternative is to reserve the last appointment time in each clinic session for same-day appointments, and be willing to work through lunch or after the regular workday until all patients have been seen.
Making open access work
Open access requires an explicit service promise from the practice to the patient. The purpose of a service promise is to manage patients' expectations and provide something against which to hold the practice accountable.
Here's an example of a service promise related to open access:
  • If you call our office before 9 a.m. and want to be seen the same day, someone in the practice will see you before the end of the day.
  • If you call our office after 9 a.m. and want to be seen the same day, you may have to wait until the next business day to be seen.
  • The provider you see (if it is not your primary physician) may ask you to make a follow-up appointment with your regular physician.
Open access can mean different things to different people.  It is vital that each practice develops its own definition.  It is also important for patients to be on notice that they may not be seen until Monday if they call on Friday after noon.
Solutions to common open access concerns

• How does a practice avoid empty appointment slots on some days and being overwhelmed on other days?

The solution is not necessarily easy, but it is simple:  Ease into open access based upon a good understanding of your current operations.  Monday mornings are probably a busy time for the phones, as patients call in about problems encountered during the weekend.  Does that mean that the practice needs more open time on Monday morning, or does Monday afternoon make more sense?
Based upon the specialty and the patient population, some types of appointments will create natural opportunities for open access and they don't have to be every week or every month.  A pediatrics practice, for example, might run an immunization or sports exam clinic for parts of several days just before school starts. • What about insurance verification?

The best answer is to have an effective way to quickly verify insurance coverage.  Supplement that process by asking patients to provide a credit card to be billed in the event the office cannot verify insurance coverage.  If the patient subsequently provides adequate, current insurance information, the practice can file the claim and have the payment sent to the patient.

Authorizing a charge in lieu of insurance is more palatable to patients when the practice is accommodating them with promptly provided care. Benefits of at least partial open access

The two primary benefits are increased patient satisfaction and improved practice productivity.  Patients are happier because they can be seen more quickly.  They are also happier because they can be seen in their regular setting with all of their records available, instead of in an urgent care center they know nothing about.

Waiting room time, within reasonable bounds, is not as aggravating when there is not a set appointment time. Practice productivity should increase for several reasons.  No shows and cancellations drop because less time elapses between the appointment and its scheduling.  Average visit lengths tend to be shorter because the visit is more focused on the precipitating issue.  Open access visits require no appointment reminders.

Courtesy of: Physicians Practice

Redetermination Requests and Submission of Documentation - Update Medicare/Noridian 03/2014

Redetermination Requests and Submission of Documentation - Update

Providers requesting a redetermination must send the request in writing stating what they are appealing and reason why they are appealing. Providers can choose to send the written request on company letterhead or by completing CMS form 20027. Noridian recommends the use of the Interactive Redetermination Form that is downloadable from the Noridian website under the Forms section.

Redetermination Requests
*At a minimum, the request letter must contain the following information:
  • Beneficiary name;
  • Medicare health insurance claim (HIC) number;
  • The specific service(s) and/or item(s) for which the redetermination is being requested;
  • The specific date(s) of the service; and
  • The name and signature of the party or the representative of the party.
*These elements are included on the Noridian Interactive Form.
Send only one (1) request form or letter per beneficiary denial. When submitting a Redetermination, please attach the required documentation to support the appealable item(s). Redetermination requests should include *ALL medical documentation pertaining to the claim or line item. Reasonable and necessary denials must include a copy of the Advance Beneficiary Notice (ABN) signed by the beneficiary if available. Also attach a corrected UB04 form.
*Noridian suggests referencing the Medical Documentation Requirements found under Resources in the Appeals Section under Browse by Topic.

The following resources can be found on the Noridian website – Appeals section:
  • Medical Documentation Requirements – Alphabetized by Item/Service
  • Signature Requirements – Explanation of valid signature and alternatives
  • Inquiries and Solutions – Answers the common Redetermination and  Reconsideration questions including Recovery Auditor (RA) appeal questions
  • Appeals Not Necessary for Certain Reason Codes - A line item or claim rejection occurs, providers may adjust the claim through the normal claim submission process, if the change does not affect liability.
  • Remark Codes – Explains Remittance Advice Remark Codes (RARCs) that are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC)

Wednesday, March 5, 2014

Road to 10: The Small Physician Practice's Route to ICD-10 From CMS

CMS has created “Road to 10” to help you jump start the transition to ICD-10.

Built with the help of small practice physicians, “Road to 10” is a no-cost tool that will help you:
  • Get an overview of ICD-10
  • Explore Specialty References by selecting a specialty
  • Click the BUILD YOUR ACTION PLAN box to create your personal action plan
To get started and learn more about ICD-10, navigate through the links on the left side of the page. If you’re ready to start building an action plan, select the BUILD YOUR ACTION PLAN box after you follow the link below:

Specialties include: Family Practice, Pediatrics, OB/GYN, Cardiology, Orthopedics, Internal Medicine and other.

Eight Easy Ways to Boost Medical Practice Efficiency

In this presentation, family physician L. Gordon Moore, who is often credited with pioneering the micropractice model, in which physicians employ no or very few staff members and rely heavily on technology, shares his top eight efficiency improvement tips.

Follow this link to view the presentation:

Claims Processing Guidance for Implementing ICD-10 - A Re-Issue of MM7492 (Medicare/Noridian)

Claims Processing Guidance for Implementing ICD-10 - A Re-Issue of MM7492

MLN Matters® Number: SE1408
Related Change Request (CR) #: 7492
Related CR Release Date: N/A
Effective Date: October 1, 2014
Related CR Transmittal #: N/A
Implementation Date: N/A

Provider Types Affected

This article is intended for all physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), and Durable Medical Equipment MACs (DME MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
For dates of service on and after October 1, 2014, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use the International Classification of Diseases, 10th Edition (ICD-10) code sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be used for dates of service on and after October 1, 2014. As a result of CR7492 (and related MLN Matters® Article MM7492), guidance was provided on processing certain claims for dates of service near the original October 1, 2013 implementation date for ICD-10. This article updates MM7492 to reflect the October 1, 2014, implementation date. Make sure your billing and coding staffs are aware of these changes.

Key Points of SE1408

General Reporting of ICD-10
As with ICD-9 codes today, providers and suppliers are still required to report all characters of a valid ICD-10 code on claims. ICD-10 diagnosis codes have different rules regarding specificity and providers/suppliers are required to submit the most specific diagnosis codes based upon the information that is available at the time. Please refer to This link will take you to an external website. for more information on the format of ICD-10 codes. In addition, ICD-10 Procedure Codes (PCs) will only be utilized by inpatient hospital claims as is currently the case with ICD-9 procedure codes.

General Claims Submissions Information
ICD-9 codes will no longer be accepted on claims (including electronic and paper) with FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2014. Institutional claims containing ICD-9 codes for services on or after October 1, 2014, will be Returned to Provider (RTP) as unprocessable. Likewise, professional and supplier claims containing ICD-9 codes for dates of services on or after October 1, 2014, will also be returned as unprocessable. You will be required to re-submit these claims with the appropriate ICD-10 code. A claim cannot contain both ICD-9 codes and ICD-10 codes. Medicare will RTP all claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim. For dates of service prior to October 1, 2014, submit claims with the appropriate ICD-9 diagnosis code. For dates of service on or after October 1, 2014, submit with the appropriate ICD-10 diagnosis code. Likewise, Medicare will also RTP all claims that are billed with both ICD-9 and ICD-10 procedure codes on the same claim. For claims with dates of service prior to October 1, 2014, submit with the appropriate ICD-9 procedure code. For claims with dates of service on or after October 1, 2014, submit with the appropriate ICD-10 procedure code. Remember that ICD-10 codes may only be used for services provided on or after October 1, 2014. Institutional claims containing ICD-10 codes for services prior to October 1, 2014, will be Returned to Provider (RTP). Likewise, professional and supplier claims containing ICD-10 codes for services prior to October 1, 2014, will be returned as unprocessable. Please submit these claims with the appropriate ICD-9 code.

Claims that Span the ICD-10 Implementation Date
The Centers for Medicare & Medicaid Services (CMS) has identified potential claims processing issues for institutional, professional, and supplier claims that span the implementation date; that is, where ICD-9 codes are effective for the portion of the services that were rendered on September 30, 2014, and earlier and where ICD-10 codes are effective for the portion of the services that were rendered October 1, 2014, and later. In some cases, depending upon the policies associated with those services, there cannot be a break in service or time (i.e., anesthesia) although the new ICD-10 code set must be used effective October 1, 2014. The following tables provide further guidance to providers for claims that span the periods where ICD-9 and ICD-10 codes may both be applicable.

Table A – Institutional Providers
Bill Type(s)Facility Type/Services Claims Processing Requirement Use FROM or THROUGH Date
11X Inpatient Hospitals (incl. TERFHA hospitals, Prospective Payment System (PPS) hospitals, Long Term Care Hospitals (LTCHs), Critical Access Hospitals (CAHs) If the hospital claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10. THROUGH
12X Inpatient Part B Hospital Services Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
13X Outpatient Hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
14X Non-patient Laboratory Services Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
18X Swing Beds If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10. THROUGH
21X Skilled Nursing (Inpatient Part A) If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10. THROUGH
22X Skilled Nursing Facilities (Inpatient Part B) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
23X Skilled Nursing Facilities (Outpatient) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
32X Home Health (Inpatient Part B) Allow HHAs to use the payment group code derived from ICD-9 codes on claims which span 10/1/2014, but require those claims to be submitted using ICD-10 codes. THROUGH
3X2 Home Health – Request for Anticipated Payment (RAPs)* * NOTE - RAPs can report either an ICD-9 code or an ICD-10 code based on the one (1) date reported. Since these dates will be equal to each other, there is no requirement needed. The corresponding final claim, however, will need to use an ICD-10 code if the HH episode spans beyond 10/1/2014. *See Note
34X Home Health – (Outpatient ) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
71X Rural Health Clinics Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/20143 and later. FROM
72X End Stage Renal Disease (ESRD) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
73X Federally Qualified Health Clinics (prior to 4/1/10) N/A – Always ICD-9 code set. N/A
74X Outpatient Therapy Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
75X Comprehensive Outpatient Rehab facilities Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
76X Community Mental Health Clinics Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
77X Federally Qualified Health Clinics (effective 4/4/10) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
81X Hospice- Hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
82X Hospice – Non hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM
83X Hospice – Hospital Based N/A N/A
85X Critical Access Hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later. FROM

Table B - Special Outpatient Claims Processing Circumstances
Scenario Claims Processing Requirement Use FROM or THROUGH Date
3-day /1-day Payment Window Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on or after 10/1/2014, the claim must be billed with ICD-10 for those bundled outpatient services. THROUGH

 Table C – Professional Claims 
Type of Claim Claims Processing Requirement Use FROM or THROUGH Date
All anesthesia claims Anesthesia procedures that begin on 9/30/14 but end on 10/1/14 are to be billed with ICD-9 diagnosis codes and use 9/30/14 as both the FROM and THROUGH date. FROM

Table D –Supplier Claims
Supplier Type Claims Processing Requirement Use FROM or THROUGH/TO Date
DMEPOS Billing for certain items or supplies (such as capped rentals or monthly supplies) may span the ICD-10 compliance date of 10/1/14 (i.e., the FROM date of service occurs prior to 10/1/14 and the TO date of service occurs after 10/1/14). FROM

Additional Information
You may also want to review SE1239 at This link will take you to an external website. on the CMS website. SE1239 announces the revised ICD-10 implementation date of October 1, 2014. 

Health Insurance Exchange Problems Hit Patients, Practices Hard

By P.j. Cloud-moulds from Physicians Practice

Wow, what a week!  What a year, I should say.  The state of California has seen many, many changes since January 1. How these changes are affecting physicians and practices is mind-boggling.

Here are a few of the biggest changes practices are experiencing: 1. A new California law allows patients to walk into a physical therapy office without a prior prescription and receive treatment for a specific number of visits or days.  The problem is that some insurance companies still require a prescription from a licensed physician.  Unfortunately, insurance companies often don't share this information at the verification level with the physical therapist, and the claim is denied or delayed in payment.  This has been a treat to figure out, but most of the patients have primary-care physicians that the physical therapist can fax the evaluation to, and this seems to satisfy the insurance companies need for a prescription. 2. The next change relates to the California workers compensation fee schedule.  It transitioned from very specific 30-minute timed codes to the Medicare Fee Schedule.  The problem is that very few of the workers compensation plans actually implemented this change and they are pulling the, “We didn't know” card.  Senate leaders in Sacramento have filed complaints against many of these plans. Liberty Mutual, your time to pay up has come!  I strongly advise practices to review their workers compensation claims with their healthcare and billing staff to make sure they are using the updated fee schedule, that the workers compensation plans are paying per the fee schedule, and that someone is following up with these types of claims. 3. Our latest fiasco has been my favorite so far:  Covered California. It really should be called Uncovered California.  This blog article is certainly not long enough to list all of the fiascos that we uncovered this week, but let me name a few.  Blue Shield created a “narrowed network" and many physicians that participate with Blue Shield are not in network on the new exchange plans. That means that if a patient purchases a Blue Shield exchange plan and calls for an appointment and a practice's front-office staff mistakenly believes it is in network, the patient may have to pay out-of-network rates around a 50 percent coinsurance for receiving services at your practice.   I have identified a common group number of X001004 and alpha prefixes of XEA, XEC, XED, XEK followed by 900.  These two are tip-offs that the patient is on exchange, off exchange, or underwritten.  All of these scenarios claims are processing out of network.Some of the health cards have the “Covered California” logo on them, some don't.  All of the plans indicate that they are some sort of PPO, so practices usually don't think twice about not being in network.  Patients are angry and up in arms about all of this.  While trying to figure this all out, I came across the Blue Shield Facebook page. If you want a laugh, take a look.  The company's canned responses are similar to the recorded messages and disclaimers you get when you call.  Blue Cross of California also has several new plans in which many providers are considered out of network.  Practices in the state of California may want to spend a few hours to identify patients with the alpha prefix JQD, JQM, JQN and VXB with corresponding group numbers of 0RX, 0RY (zero not “O”).  It is imperative that practices discuss these out-of-network issues with their staff so that they are aware when patients call and start yelling about getting their bills.

Article From Physicians Practice

Improve Your Medical Practice Billing Process in a Few Simple Steps

By P.j. Cloud-moulds from Physicians Practice

My old primary-care physician was a really great physician.  She spent enough time with me, asked great questions, was always available, and took very good care of me.

So then why is she no longer my physician after fifteen years? Because of the back-office billing staff. They were rude, unorganized, didn't know how to post payments for the life of them, and continuously billed me in error. This is a very, very common problem in most physician practices.  Have you read your Yelp or Healthgrades reviews?  They may say something like: “My doctor's care was great, but the billing office experience was awful.”  If this is the case in your practice, fear not. I have cracked the code on customer service in the billing department. At my practice, I started testing this new process after an outstanding brainstorming session with my staff.  They were very eager to change the flawed billing process, and we fumbled through a few revisions before we finally got it right. Here's what we do:

  •  Once we close the month for processing, statements are run.
  • Immediately, we review each and every statement.  It took us about three months to clean up the riff raff that was plaguing accounts receivable
  • During the statement review,  we consider four important questions:
    1.  Did our system post the monies properly, and is this a true patient balance?
    2. Has this patient been on the A/R list for more than 90 days? If yes, we send them a pre-collections letter.  If they then don't pay within 15 days, we send them to collections.
    3. If the patient is showing a balance, is it because it was not processed by the insurance per the original verification?
    4.  If the patient is showing a balance, is it because it was not collected up front or posted properly in the system?  We also identify the exact date of service a payment is missing.
  • Once we have reviewed all of the statements and we have identified true statement balances, we check in with the front-office staff to see if they have receipts for those specific dates of service.  If they have receipts, we post them and remove the statement from the list going out. 
  • We document this information in an easy to access spreadsheet-type format so that when patients call in, we have already identified the problem and can quickly, and efficiently answer their question with full confidence.
By spending about four hours of time up front, we ended up saving three full-time staff the better part of an entire week that would have bent spent dealing with billing headaches.  That's pretty good ROI. 
Make strides towards providing a good billing experience for your patients.  We have and it has made all of the difference in the world.  Remember, “That's just the way it is” is a crutch and an excuse for not being brave enough to change what needs changing.

Article from physicians Practice: