Doctors contemplate opting out due to continued Medicare hassles

Physician participating in the Medicare program are scheduled to face a 27.4% cut in their payments, effective 1^st January, 2012, and with providers anyway complaining about current reimbursement rates, the cut is likely to considerably impact both patients as well as doctors adversely. As a result of the cut the Medicare physician conversion factor will decrease to $24.67, approximately $15 less than it was in 2001. In this scenario, the Association of American Physicians and Surgeons reports that various physicians are declining to take on new Medicare patients and many are thinking about cancelling enrollment from the program.

Medicare hassles:

Since the past 10 years physicians and Congress have been grappling with similar situations; however the difference which is pushing doctors to consider opting out is the severity of the cut and the escalating costs of a permanent solution, and few can continue to operate in an environment where revenues are cut by 27% while costs continue to rise at a rate of 3% or higher. An internal medicine physician in New London whose approximately 80% patients are covered by Medicare, with this cut is likely to lose about one-third of his revenues, possibly forcing him to restructure his entire practice.

Another issue that has created problems for Medicare beneficiaries and their medical providers for years is the sluggishness of the claims process and the payment process. Medicare doctors in three western states – California, Hawaii and Nevada, are in a situation where Medicare’s payment backlog has created a multimillion dollar problem.  Various doctors have not been paid since February, a backlog of almost 10 months,  forcing some doctors to have to drop some or all of their Medicare patients while others are on the verge of declaring bankruptcy or have already done so.

Physicians’ current & upcoming scenario:

President of the New London County Medical Society said that the prolonged uncertainty about Medicare reimbursement rates has motivated some doctors to take an early retirement. A survey by the Medicare Payment Advisory Commission (MedPAC) indicates that by 2025 there will not be enough primary care physicians. Additionally, this cut comes at a time when physicians face potential penalties associated with  HIPAA 5010 , electronic prescribing, ICD-10, PQRS and electronic health records which are difficult to adhere to in a time of dramatically falling revenue.

However, even though physicians are pushed to consider other options, in the next 20 years senior citizens requiring Medicare will rise, and doctors who can sustain the current pressures and adapt to the reforms have a vast potential for growth. The physicians need to face this challenge of payment cuts by making their system more efficient; reduce their extra administrative burdens and revamp their revenue cycle giving them a competitive edge. Medicalbillersandcoders.com can optimize physicians’ billing process and reimbursement cycle, which will help doctors maintain their revenues as they tackle Medicare issues.

Utah Medical Billing | Pediatrics Medical Billing

Physicians to make the most of 5010 Enforcement Delay

Physicians were mainly relieved with the announcement made by Centers for Medicare & Medicaid Services (CMS) Office of E-health Standards and Services (OESS) on 17^th November, to delay enforcement of Health Insurance Portability and Accountability Act HIPAA 5010  transaction standards with a 90-day discretion period for all HIPAA covered entities. CMS stated that their decision is based on industry feedback that a number of organizations and their trading partners would not be able to finalize system upgrades to 5010 standards in time with the initial 1^st January, 2012 deadline.

Contrary to what many physicians anticipated, the process of transitioning from Version 4010 to 5010 is much more difficult, hence the delay has been a boon for physician’s practices, if CMS had not taken this step there could have been a possibility of a revenue-cycle train wreck.

Any claims or bills submitted after January 1, 2012, that are not in HIPAA 5010 will still get rejected, but delay in enforcement allows physicians to resubmit in the appropriate HIPAA 5010 format without penalty, hence it is imperative for doctors who have not upgraded to HIPAA 5010 to utilize the next 90 days to upgrade to 5010 standards. Survey by the Medical Group Medical Association (MGMA) estimated that upgrading to HIPAA 5010 could set providers back $16,575, and 45.2% of practices have not yet started the implementation of software upgrades necessary for HIPAA 5010.

Practice’s preparing to implement 5010 standards –

• Update software to work under the new standards and contact the software vendors, claims clearinghouses and payers to verify that they are operating as per 5010 standards
• Practices without up-to-date software can take what Hawkins called the “secondary path” of asking their billing clearinghouses if they are translating claims transactions from the 4010 format to the 5010 standard

As the transition to HIPAA 5010 standards is a necessary step before moving to the ICD-10 set of diagnostic codes physicians need to gear up for the changes. In this crucial time of healthcare reforms physicians short of time can benefit from partnering with experts who can handle their entire revenue cycle, in order to concentrate more on streamlining their process and enhance patient care. Even looking out for a software change to HIPAA 5010 compliance Medical Billing software could ease the pressure of physicians trying to migrate to a software solution.

Medicalbillersandcoders.com expert consultancy and software advice services support healthcare providers across the US with their revenue cycle management. MBC also offers professional support and assistance to healthcare providers to keep abreast of the changing industry norms, so that they can concentrate on their core services such as patient care.

Florida Medical Billing | Podiatry Medical Billing

Radiology: Finding New Meaning in “Meaningful Use”

Radiologists in the United States are currently facing a dilemma as far as “meaningful use” (MU) of Electronic Health Records (EHRs) is concerned. The American College of Radiology (ACR) IT and Informatics Committee leaders and staff have met the National Coordinator for HIT (ONC) as well as Center for Medicare and Medicaid Services (CMS) staff to discuss the HR incentive program from the point of view of radiologists, on October 13, 2011.

The American College of Radiology committee reiterated its previous requests for certain criteria regarding meaningful use such as – the sharing or accessing imaging data as part of Meaningful Use, robust radiology order entry requirements for referring physicians with appropriate clinical decision support, and addressing Meaningful Use challenges within the radiology community and other specialties.

The American College of Radiology Meaningful Use Report

A report released by the ACR regarding Meaningful Use for radiologists specifies the steps taken by the CMS regarding some of the “Core” and “Menu” objectives and their relevance to radiology. The reports summary states that according to the Continuing Extension Act, outpatient hospital settings (POS Code22) are not considered hospitals in the EHR incentive program. A vast majority of radiologists will be eligible for the Medicare version of the EHR incentive program.

Defining Hospital-based Physicians

The report by ACR also states who would be considered as hospital-based by the CMS and would be ineligible for the incentive program. The CMS defines hospital-based physicians as those providing 90 percent or more of their covered professional services in inpatient (POS Code 21) and emergency room (POS Code 23) settings. Therefore hospital-based radiologists who do not meet the above mentioned criteria are eligible for the Medicare incentive program. However, Medicaid eligibility has stricter rules that require the EP’s 30 percent volume must be attributable to Medicaid which is a tall order for any radiologist if not impossible.

Who is Qualified?

The Medicare version of the incentive program only applies to physicians and radiologic technologists, medical physicists, or other technical staff is not eligible. However, the Medicaid version of the incentive program is limited to physicians, Certified Nurse Midwives, Nurse Practitioners, and Physician Assistants who furnish services in a Federally Qualified Health Center or Rural Health Clinic that is led by a Physician Assistant.

Radiologists vs. Primary Care

The meaningful use objectives appear to be focused on primary care and present some confusion as to how radiologists would comply with such objectives. However, CMS provides exclusions to many meaningful use measures as well as “menu set” measures to counteract this problem to adjust specialties such as radiology.

RIS and PACS

According to the report by ACR many HIT products that are not considered traditional, complete EHR/EMR could still achieve certification via the EHR module pathway. However, these modules need to be tested and certified before they are considered certified EHR technology. Moreover, there are advanced RIS solutions that have already received complete EHR certification or are in the process of receiving it. This implies that RIS/ PACS can be adopted so as to be certified EHR technology in the near future.

The Exclusions for Radiology in Core and Menu Objectives

Out of the 15 core objectives there are nine that are not excluded and are – Drug-Drug and Drug-Allergy interaction checks, update problem list, medication list, medication allergy list, record demographics, report clinical quality measures to CMS, implement CDS rule, HIE test, and security risk analysis. For all other core objectives, exclusion is available for radiologists. As far as the “menu” objectives or discretionary objectives are concerned, only two out of the ten objectives are given exclusion for radiologists. These two menu objectives exclusions are – generate list of patients by specific conditions and patient-specific education resources. All the other eight objectives are not excluded for radiologists.

The anxieties over radiologists’ eligibility for the incentive program are now slowly being dissolved due to the correction and amendments made by ONC. The vast majority of radiologists are eligible for incentives; even those that are hospital based, if they meet certain criteria laid out by the ONC.

For more information about “meaningful use”, EHR certification and implementation, PMS implementation, consultancy, and medical billing and coding services, please visit medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States.

Dealing with overpayments in your practice

“Simple it might seem, yet given the time and the resources that such monitoring and reporting eventually consumes, physician practices can find it hard to take up such intensive scrutiny amidst the overriding challenge of keeping their medical service quality benchmarked to the perennially raising medical standards. All such apprehensions point towards outsourcing medical billing management that comes with the value-addition of surveillance-check on Overpayments”.

Strange it might seem, frequency of overpayments from insurance carriers, particularly Medicare, seem to grow as the volume of health insurance claims swells with each passing day. Irrespective of the reason, whether stemming out of up-coding or lapse on the part of the payer, it is never recommended that you keep the overpayment without informing your medical insurer. As Medicare has made it mandatory for physicians to report any incident of overpayment within 60 days from the actual day of receiving such payment, failure to comply by scheduled time-frame can constitute fraud and abuse inviting penalties, such as cancellation of practice-license, monetary penalty, or imprisonment depending upon the severity of the intentional fraud and abuse. More than the material punishment, it is the credibility that you may be risking while going for unscrupulous overpayments.

Having convinced of the efficacy of reporting overpayment, now it is time to know how to report, whom to report, and how to be immune to such overpayments:

Upon finding out overpayment, the physician concerned should write a refund note to the Medicare carrier along with a brief explanation of the reason for the refund; certain extraordinary cases may need to be reported to federal and/or state criminal authorities such as the Department of Justice or the Office of Inspector General (OIG).

Further, there needs to be consistency in reporting overpayments: reporting selective or randomly may not be sufficient for building goodwill with your payer as it still opens up chance for audit exposure
Appoint your staff to specifically look into the genuineness of payment posting, and monitoring of the actual realization against the claim realization.

Simple it might seem, yet given the time and the resources that such monitoring and reporting eventually consumes, physician practices can find it hard to take up such intensive scrutiny amidst the overriding challenge of keeping their medical service quality benchmarked to the perennially raising medical standards. All such apprehensions point towards outsourcing medical billing management that comes with the value-addition of surveillance-check on Overpayments. Therefore, it becomes crucial that your prospective medical biller’s scope of Revenue Cycle Management – along with the usual patient scheduling and reminders, patient enrollment (demographics and charges), insurance enrollment (for physicians and offices),

Insurance verification, insurance authorizations, coding and audits, billing and reconciling of accounts (payment posting), account analysis and denial management (EOB analysis), AR management (insurance and patient), financial management reporting – is inclusive enough to identify and report such odd incidents of overpayments.

Medicalbillersandcoders.com being a leading provider of such inclusive medical billing revenue cycle management, holds key to physicians’ endeavors towards honest and credible practice management.

Better Payer Interaction for Physicians

Payer interaction plays a crucial role in ensuring that physicians receive payments in a fair and timely manner. Medical billers and coders who interact with payers need to stay current with major payers (insurance companies, employers, or the government) in order to make sure that errors and delays can be avoided. The changes in the health industry have made it necessary for the billing staff to stay abreast of the changes in policies and guidelines so as to be efficient and useful at the same time. There are many facets to payer interaction and the billing cycle such as efficient denial management, using correct medical codes, correct payment posting, and interacting with physicians about any changes in such processes.

Coping with Changes
The health industry in the country is undergoing unprecedented changes such as migration from ICD-9 codes to ICD-10, Electronic Medical Records implementation, advances in the health IT sector, and the way physicians would be paid in the future. Medical billers and coders need to be current and updated on these changes along with changes in the insurance sector. There are numerous ways of keeping abreast of such changes such as visiting insurance and government websites on a regular basis and making use of newsletters among other things. The best example of such a newsletter is by CMS which has started the “Medicare Quarterly Provider Compliance Newsletter: Guidance to Address Billing Errors” which addresses issues related to the most common billing errors in the industry.

The Tragedy of Errors
The latest American Medical Association (AMA) report on payers points out that payers make mistakes in claims-processing to frustrate physicians and patients. The National Health Insurer Report Card gives details of various parameters such as accuracy, cash flow, payment timelines, improvement in claims cycle workflow, and administrative requirements – Prior authorizations which are distributed into 17 metrics. The major private payers in the country are compared in the report and include Aetna, Anthem, CIGNA, HCSC, Humana, Regence, and UHC. CIGNA has the lowest claims denial rates among these and Anthem, the highest. However, the average claims-processing error rate among these commercial payers is a staggering 19.3%, according to the latest report released in June 2011. This fact itself magnifies the importance of professional medical billers and coders who can successfully identify such errors by interacting with payers and ensure timely payment for physicians and health care providers.
  
 Time
The time spent by physicians interacting with payers, according to a study published in the health policy journal Health Affairs, is almost three hours a week. The cost of such interaction on a national scale is estimated by the study is about $23 billion to $32 billion each year. It is apparent that physicians cannot afford to spend so much time, money and effort in dealing with insurance companies and payers when more and more people are being insured due to the health reforms. The only viable option available for physicians is to outsource the whole process of interaction with payers to a third party that is experienced in this field. The reluctance of payers to reimburse physicians and the increasing workload of health care providers is making time a scarce commodity which is further exacerbating the problems faced by physicians and their staff.

Post Health Reforms
The health reforms in the form of Patient Protection and Affordable Care Act would ensure that more people enjoy health benefits. Insurance companies would not be able to drop policyholders when they get sick and millions of uninsured would be provided with efficient health insurance plans. However, insurance companies would try to find more ways of denying claims or underpaying physicians even when health providers would be working long hours. The need for interacting with payers would be more than ever before due to the easy access to health cover for many people. The efficiency of such interaction can only be increased with dedicated professionals who have the knowledge and expertise in this field and who know the pitfalls and opportunities that present themselves while extracting payments from insurance companies.

Physicians and health care professionals have borne the brunt of stinginess by insurance companies for a long time and it seems that with the reforms, payers would be reined in. However, it remains to be seen whether there would be a positive change in the attitude of payers in the future when it comes to prompt and timely reimbursement of providers.


For more information about payer interaction, consultancy, and professional medical billing and coding services please visit medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States.

Standards of ethical Medical coding: Part 2

Coding is one of the core functions of healthcare providers and, due to the complex regulatory requirements impinging upon the health information coding process; the coding professionals are frequently faced with ethical challenges. There are stringent medical guidelines in place for the entire gamut of coding practices which include issues such as the privacy of patient healthcare data, accuracy, and regulation compliances.

This series of tutorials will help medical coders get comprehensive information about the standards of ethical medical coding norms and assist them in making ethically correct decisions in the workplace; these parameters can help evaluate the coding professionals’ commitment to integrity during the coding process.

Following are the set of guidelines recognized by AHIMA for ethical medical coding: 
Confidentiality
Coding professionals are liable to keep medical information private. As they are responsible for the transfer of information between doctors and insurance companies so integrity is of high importance in this profession. Coding related process includes completion of code assignment, coding audits and other healthcare data abstraction.

Coding professionals who handle medical information are generally required to sign confidentiality and non-disclosure agreements. To mitigate the risk of PHI handling, employers in the healthcare facilities have clauses in their contracts against intentionally or unintentionally data misuse which even subject them to prosecutions. If found guilty it can even lead to a fine up to $250,000 and/or imprisonment for up to 10 years, this not being the only reason for adherence to patient data security; Coders also comply with the following:

1. a. Patient’s information is only shared with health insurance companies. Patient’s medical history is not revealed to third parties
2. b. Confidentiality of the health records including personal, health, financial, genetic, and other information is protected with utmost care.
3. c. Ethical coders do not access protected health information which is not required for coding related process, it is with great trust that a patient shares this information with providers – it is vulnerability of the system which demands that other administrative staff has access to such crucial information.

The entire system of data handling is individually responsible for preservation of confidentiality of the PHI, especially certified and experienced Medical Coders.

Medicare learning network Updates Medicare Claim Submission Guidelines

Center of Medicare and Medicaid services has released fact sheet on Medicare claim submission guidelines. The fact sheet offers billers, coders and physicians up-to-date guidance on how to file Medicare Claims. Following are some important points mentioned in the fact sheet:

Timely filling of claim is one of the important guidelines mentioned in the fact sheet. Payment for any claim can only be received if the claims are received on time i.e. Claims with date of service on or after January 1, 2011 must be received no later than one calendar year from the claim’s DOS. Claims that are filed after the specified timeframe will be denied with no appeal rights. For claims that include span dates of service, claims filing timeliness is determined as follows:

• The “Through” date is used to determine the date of service for institutional claims; and
• The “From” date is used to determine the date of service for professional claims.

However there are some exceptions in the filling of claims. Billers and coders are not required to file claims when
a) The claim is for services for which:

• Medicare is the secondary payer;
• The primary insurer’s payment is made directly to the beneficiary; and
• The beneficiary has not furnished the primary payment information needed to submit the Medicare secondary claim;

b) Physician has opted-out of the Medicare Program and entered into a private contract with the beneficiary; or physician have been excluded or debarred from the Medicare Program.
c) The claim is for items or services furnished outside the U.S., except in limited cases
d) The claim is for services initially paid by third-party insurers who then file Medicare claims to recoup what Medicare pays as the primary insurer (e.g., indirect payment provisions)
e) The claim is for other unusual services, which are evaluated by Medicare Contractors on a case-by-case basis
f) The claim is for excluded services, unless the beneficiary requests submission of a claim to Medicare (some supplemental insurers who pay for these services may require a Medicare claim denial notice prior to making payment)
Apart from these guidelines the factsheet also contains information on

• How to apply for a national provider identifier (NPI) and enroll in the Medicare program
• How to Opt out of Medicare and arrange private contracts with Medicare beneficiaries

Medical billing and coding professionals can keep themselves updated with latest healthcare industry updates by visiting www.medicalbillersandcoders.com

Salary survey 2011 for coders

Salary survey for coders is out for year 2011. The survey is carried out amongst 12,000 respondents; the survey clearly shows an upward trend in average salaries for coders. The survey has also brought out some key trends in coders hiring, region wise average salaries and various career paths coders are opting for.

Let’s have a look on some key trends

Region wise salaries:

Average Salaries varied region wise pacific region saw highest salary with $ 53,334 per annum for a coder while east south central $39,830 per annum. Coders in states with a higher cost of living were paid more than those in states with a lower cost of living. For example, coders in California earned in excess of $57, 700, while workers in Kentucky earned just under $37,500.

Average salaries based on nature of employment
Source: AAPC survey

Average salaries also varied on the basis of nature of employment Self employed individuals have earned average of $69,150 per annum while the coders working in solo practices have earned average salary of $39,920 per annum. 

Coders take variety of career paths

Surveys also indicated that coders are taking variety of career paths, with health reform, electronic health records( EHR’s) and ICD-10 they have various options to choose .The common choices were like as coder, management, biller/collector, charge entry, auditor, educator, consultant, claim adjudicator.

These various trends are the evidence of growing demand for skilled coders in a tough economic and health reimbursement scenario.Medicalbillersandcoders.com provides a comprehensive platform for billers and coders to get the maximum advantage of this growing demand by bridging the gap between them and providers.

Physicians see value in handling Claim Denials in a Better Way

Appealing denied claims is one of the important steps in enhancing the revenue of physicians and this fact is supported by a report by the U.S Government Accountability office (GAO). The report released on March 16, 2011 states that – “coverage denials occurred for a variety of reasons, frequently for billing errors, such as duplicate claims or missing information on the claim, and eligibility issues, such as services being provided before coverage was initiated, and less often for judgments about the appropriateness of a service. Further, the data GAO reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer’s favor.” 

Percentages in Favor of Denial reversal
The GAO report also mentions that data from four of the six states on appeals indicates that about 39 to 59 percent of appeals resulted in the reversal of denials by insurers. Almost 10 percent of physician revenue is lost due to the lack of a proper denial management process. Therefore, the percentages are in favor of physicians if they adopt a professional attitude towards denial management and ensure that errors do not affect their bottom line. 

Post Reform Denial Management
The health reforms in the country under the Patient Protection and Affordable Care Act (PPACA) of 2010 could expand insurance cover to almost 31 million uninsured citizens. This can have a two-pronged effect on the revenue of physicians, in that, there would be greater scope of increasing revenue while at the same time, payers would find new reasons and even technical errors to deny claims. In face of such an unprecedented change in the insurance sector, it makes sense to ensure that the denial management process is set up considering the long term benefits that such management can provide. 

Common Reasons for claim denials
The most common reasons for claim denials are due to a wrong diagnosis, incorrect procedure code or incorrect place of service being billed, the wrong modifier or lack of modifier being billed, the claim was billed without a provider number, denials due to policy limitation such as late filing or late appealing, a claim denied due to the prescription drug issues, or due to non authorization from a primary care physician when a specialists services are used are quite common. However, there are other simple reasons such as medical billing and coding errors or missing/duplicate information. The most avoidable of these reasons are errors in medical billing and coding which prolongs the time for receiving payment for services rendered. 

Coding Complications
The changes in ICD codes are another factor that would heavily influence the results of appeals and denied claims. The transition from ICD-9 codes to ICD-10 codes is taking place in the medical billing and coding industry which is unprecedented if not complicated in nature, The new ICD-10 codes are more elaborate compared to the older ICD-9 codes and thus increase the possibility of errors while coding. The staggering number of ICD-10 codes compared to ICD-9 (almost 9 times) can prove to be cumbersome for medical billers and coders who are not experienced or do not have proper training in the new codes. Therefore it becomes important to outsource medical billing and coding to professionals who are ready to implement such transformation in an effective manner. Complacency in this field can lead to delayed or even lost revenue for physicians and health care providers. 

The Bottom Line
It cannot be denied that with so many changes taking place in the health industry such as EMR/EHR implementation, insurance policy overhaul, and numerous coding changes, there are bound to be errors in some of the aspects in denial management or in other aspects of delivering health care. However, the bottom line of physicians should not be affected just due to avoidable errors in medical billing and coding. Outsourcing the process of denial management and medical billing and coding to a responsible professional entity can make a huge difference in the revenue and the way revenue cycle management is carried out.
For access to more information about denial management, medical billing consultancy, and professional medical billing and coding services please visit medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States.

Tax Exemptions for Physicians in Underserved Areas

The tax exemptions for physicians serving in underserved areas are no longer limited to a few states and have expanded to the whole nation, according to the IRS. The Affordable Care Act makes provision for professionals who received student loan relief under state programs that reward those who work in underserved communities may qualify for refunds on their federal income tax for the year 2009 and annual tax cuts after the year 2009. Prior to these changes (2009) the only amounts accepted under the National Health Service Corps Loan Repayment Program or some state loan repayment programs qualified for funding under the Public Health Service Act were eligible for tax exclusion. 

Eligibility

Under Section 10908 of the new Patient Protection and Affordable Care Act, existing tax exclusion has been extended to add in health professionals in sixteen states who are signed up in these sorts of state loan forgiveness or loan repayment programs. The IRS press release (dated June 16, 2010) also states that health care professionals taking part in these programs who previously have reported income from repaid or forgiven loan amounts on their 2009 returns probably after accepting a Form W-2 Wage and Tax Statement or a Form 1099 may be qualified for refunds. 

The new Patient Protection and Affordable Care Act (Section 10908)

The new Patient Protection and Affordable Care Act states under section 10908 that – “Payments under National Health Service Corps loan repayment program and certain loan repayment programs- In the case of an individual, gross income shall not include any amount received under section 338B(g)of the Public Health Service Act, under a State program described in section 338 I of such Act, or under any other State loan repayment or loan forgiveness program that is intended to provide for the increased availability of healthcare services in underserved or health professional shortage areas (as determined by such State)”. 

Employees and Professionals who filed for Extensions

Health care providers who have filed for extensions and have not yet filed taxes for the year 2009 are not obligated to report eligible loan repayment or forgiveness amounts when they file. Those who by now have filed may leave out eligible amounts by filing an amended U.S. Individual Income Tax Form. Moreover, according to the IRS press release, individuals whose employers withheld and paid taxes under the Federal Insurance Contributions Act (FICA) – which funds the Social Security and Medicare programs – on payments covered under the latest exclusion may appeal that the employers request repayment of pending FICA tax amounts on behalf of their employees. 

Related Tags:Georgia Medical Billing, Hawaii Medical Billing 

Medically Underserved Areas

Medically underserved areas can be found on the Health Resources and Services Administration (HRSA) website. According to the HRSA, as of September 21, 2011, there are 6,433 Primary Care Health Professionals Shortage Areas (HPSA) with 66.9 million people living in them and would take 17,798 practitioners to meet their demand for primary care providers. There are 4,675 Dental HPSAs with 52.4 million people living in them and would take 10,242 practitioners to meet their need for dental providers. There are 3,795 Mental Health HPSAs with 95.3 million people living in them and would take 6,252 practitioners to meet their need for mental health providers. 

The Pros and Cons

The tax relief offered for providers or physicians in HPSAs coupled with the incentives for successfully demonstrating and utilizing Electronic Medical Records (EMR) or Electronic Health Records (EHR) makes a lucrative offer for physicians to work in such underserved areas of the country. However, it cannot be denied that the shortage of physicians and providers coupled with expansion of health coverage for all citizens would essentially mean busier times ahead for health professionals; especially in rural and underserved areas.

For more information about professional medical billing and coding services, Electronic Medical Records (EMR) or Electronic Health Records (EHR) implementation issues and Revenue Management consultancy, and please visit medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States.

Gearing Up for Inpatient Medical Coding and Reimbursement Challenges

“The prevalence of such demanding challenges is reason enough to push physicians beyond their Medical Billing Management capabilities, which invariably results in compromised medical efficiency. Therefore, physicians – faced with insurmountable challenges of inpatient medical billing management – have either to set up a dedicated team in-house or look elsewhere for competent outsourced solutions.”

Unlike coding and reimbursement for Outpatient Services, Hospital Inpatient coding and reimbursement is altogether a different proposition – the extensive diagnostic, preventive, and curative procedures administered over a considerable time of patient-stay at the hospital demand accurate charge-capture, billing, compliant coding, and timely claim submission. Further, the overlapping nature of medical situations prompts apt application of Modifiers to nullify the probability of claim denials by insurance carriers.

The prevalence of such demanding challenges is reason enough to push physicians beyond their Medical Billing Management capabilities, which invariably results in compromised medical efficiency. Therefore, physicians – faced with insurmountable challenges of inpatient medical billing management – have either to set up a dedicated team in-house or look elsewhere for competent outsourced solutions. While large hospital set-ups can withstand the heavy investment outlay required to set up such dedicated in-house Medical Billing Management, it is the marginal individual practitioners who find the scenario tough manage. For such population of physicians, outsourcing seems to be the only recourse.

While the market is flooded with innumerable service providers, yet, it is advisable that an apt and competent provider is engaged for the occasion. The following underlying factors should be of invaluable help in choosing ideal one for the occasion:

• Does your service provider possess reimbursement and methodologies specific to inpatient practice settings? One of the primary requisites, the service provider’s adequacy in reimbursement and methodologies specific to inpatient practice settings will go a long way in determining the requisite qualification for taking on the incumbent challenges.
• Is your service provider capable of Structuring and organizing of Medicare inpatient acute care Prospective Payment System? Although specific to Medicare beneficiaries, yet, it is important to gauge your service provider’s ability to devise such ingenious measures as your practice is bound to encounter a majority of Medicare patients.
• Does your service provider understand the relationship between coding and Diagnostic Related Group (DRG)? As the your practice is likely to encounter several incidents that have affinity to DRG based coding for inpatient medical services, it is important to screen your service provider for the capability in relating coding and Related Group (DRG)
• Does your service provider possess the data quality and coding compliance processes related to coding and reimbursement for inpatient services? Data quality, the foundation on which an efficient medical billing management thrives, is of utmost importance. Therefore, it is necessary to establish the presence of EHR system in compliance with HIPAA norms. Further, it is equally important to know how best such a system is utilized for compliant coding and reimbursement processes involved in inpatient set-up.

Related Tags:District Of Columbia, Florida 

Coupled with such a comprehensive screening program prior to selection of an apt service provider, care must also be taken to assess your service provider’s proactive outlook to ICD-10-CM and ICD-10-PCS, and their impact on inpatient reimbursement; affinity to information on Recovery Audit Contractors (RAC) audits, keeping abreast with information on MS-DRGs and Medicare reimbursement in other inpatient settings; and materials on periodic changes in coding, and coding compliance.

Whereas such a screening is indispensable for avoiding being embarrassed with wrongful choice, the task is usually resource and time-consuming – forcing physicians into a quandary. Fortunately, Medicalbillersandcoders.com (www.medicalbillersandcoders.com) – complete with accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards – should make their selection process easier, less-time and re-source consuming.

What rules the roost in healthcare organizations: financial stability or patient care?

“Propensity to be fascinated by both the extremities should scrupulously be avoided, and thought must be given to finding an ideal balance between Financial Stability and Patient Care”

Unlike Public or Community Healthcare centers, which are funded and run by Federal Healthcare Department, the private healthcare centers have to find their own course to a sustainable means of practice amidst an intensely competitive healthcare industry. As most of these private practices are run by physicians themselves, they find themselves in a rather tricky situation as to whether financial stability should take precedence over patient care, or vice-versa. It is quite interesting to note that those who favored financial stability over patient care had to be contented with dwindling patient base, and those who thought of charitable patient care had a rather dismal show of revenue generation. Amidst this living example, propensity to be fascinated by both the extremities should scrupulously be avoided, and thought must be given to finding an ideal balance between Financial Stability and Patient Care. Then, how can practices strike such a balance?

Well, physicians would agree that their patients are the primary source of revenue generation. Further, they would also vouch that efficient medical care distinctively superior to their competitors gives them a better chance of not only retaining the existing customers but also garnering newer ones. Whereas such outlook can take care of marketing your practices for patient solicitation, an efficient medical billing management should ensure revenue generation in congruence with physicians’ marketing efforts. But, because of medical billing management being too exhaustive owing to highly stringent reimbursement environment, physicians have felt them to be too demanding and detrimental to their focus on efficient medical care. Therefore, in order to find an amicable balance between revenue generation, and patient care, it is prudent to outsource revenue optimizing billing management, while carrying on with what they know best – patient care. 

Finding an amicable balance between financial stability and Patient care…

• How outsourced Medical Billing Management can ease the pressure on financial Front?
• Establishing the credibility of the insurance policies held by the patients: Physicians would do well to establish the credibility of the insurance policies so as to avoid running into dubious insurance carriers. A proven medical billing management solution can be of indispensable help in this regard.
• Verifying the existence of a valid insurance policy: Verifying the existence of a valid medical insurance will go a long way in ensuring physicians that their medical bills will be reimbursed for sure. By establishing such an existence or otherwise, outsourced medical billing management can save physicians from undesirable embarrassment.
• Advising on the importance of implementing Electronic Health Recording (EHR) system:
  Medical Billing Management, as part of their comprehensive solution, offer advice on the efficacy of installing EHR, which along with being cost-effective, ensures seamless integration and dissemination of health care date for billing, referencing, and future research.
• Installation of advanced technology platforms for Billing and Coding: One of the important functions of an outsourced medical billing service, infusing technology platforms into billing and coding management saves not only time and resources but also expedites the process of medical billing claim submission.
• Proven Expertise in Coding: Being qualified and well-versed in coding system, medical billing management solution provider ensure greater accuracy in medical coding for delay-free and denial-free reimbursement of their clients medical claims.
• How Physicians can optimize their Healthcare Marketing Efforts for greater patient influx?
• An engaging patient care model: Physicians, on their part, would do well to engage their patient with a close and involved medical care, involving continuous dialogue and advice on social networks, and personal feed-back on status and progress of treatment to gain and build a confidence-enhancing environment.
• Perpetual knowledge enhancement through extended learning: Further, physicians, by being proactive to breakthroughs in medical care, can ensure quality medical care to their trusting patients. By doing so, they stand to gain in terms of retaining the existing patients, who can potentially be referral for newer patients.

Thus, a two-pronged effort on both the fronts is vital to an ideal balance between financial stability and quality patient care.

Medicalbillersandcoders.com, with a substantial hands-on experience and expertise for not only ensuring financial stability, but also turning around a majority of practices across the United States, should be your ideal ally in finding an amicable balance between financial stability and quality patient care.

Towards Cleaner Claim Submission and Realization

Despite vigilant system of medical claim submission practiced by physicians, the recent statistics released by the American Medical Association (AMA), has reported an increase in medical billing inaccuracies by 2% over the last year’s results. What is more significant is – apart from delay or denial owing to inherent error-prone claim submission – the estimated spend of $ 1.5 billion in rectifying, resubmission, and realization of the medical bills, originally returned for inaccuracies. Therefore, physicians need to realize the importance of intensifying their vigil while preparing claim sheets. While an internal check for undesirable errors can do the trick, physicians need to know the stages where these errors/mistakes get uploaded into the claim sheet. Usually, mistakes are known to happen during:

• Patient’s insurance verification
  Patient’s insurance verification, which establishes the existence of a health insurance for coverage of their medical expenses, is the foremost thing while preparing a medical claim sheet. Acting on the presumption that health insurance is universally prevalent could land you into trouble. Therefore, physicians need to guard against any complacency. 
• Patient’s insurance authorization
  Although patient’s verification does prove their eligibility or otherwise for medical bill reimbursement, patient’s insurance authorization further screens their eligibility for coverage for the medical situation for which they are seeking treatment. Therefore, it is doubly important that physicians satisfy themselves with this authorization from the insurance carrier, and avoid getting embarrassed later on.
• Medical Bill Preparation
  An inclusive and comprehensive medical bill preparation is the foundation to a satisfactory claim realization. Therefore, physicians need to bill for those services that are directly related to the treatment as well those that are incidental and medically deemed allowable. Practicing such inclusive and conclusive medical billing saves physicians from either undercharging or overcharging their services.
• Medical Coding
  Perhaps the most significant area that is more prone to error, apt medical coding is the underlying factor in either minimizing or nullifying the propensity of errors. Consequently, physicians need to be thorough with the prevailing ICD coding manual for diagnostic and procedural services. Such diligent coding can only ensure accurate coding in congruence with the ICD system of medical services coding, and error-free/denial free realization of medical claims.
• Infusing apt Modifiers
  Due to the overlapping nature of medical procedures, more often than not, medical services are increasingly difficult to define within the governing ICD codes. Such cases demand scrupulous application of modifiers to establish the necessity for overshooting the prescribed limit of medical service. Along with establishing the necessity, modifiers also enable physicians to realize medical claims inclusive of incidental or medically deemed/allowable charges. Therefore, physicians should judiciously mix modifiers wherever necessary as they can not only nullify denial factor but also improve the prospect of inclusive revenue-generation.

These indicators point out the necessity of further modifying the laborious system of medical billing management, and sprucing up with highly technological system of medical billing and payment that would effectively remove the lacunae – such as too labor-intensive, error-prone and far too fragmented – in the prevailing system of medical billing management.

But, with physicians’ focus firmly on medical care, asking for such radical shift would be too demanding. Therefore, physicians, inevitably, have to look up to tried and proven outsourced solutions in medical billing management for lending their claim-sheets with the adjective, ‘clean and honest’. During such trepidation, Medicalbillersandcoders.com (www.medicalbillersandcoders.com), having been an indispensable catalyst to physicians’ medical billing management, should make the search easier. With impeccable credentials for providing error-free billing across specialties in the US, Medicalbillersandcoders also provides consultancy services for optimizing your revenue management cycle.

Towards Minimizing Legal Errors In Handling Medical Records

Despite such indicators from time to time, the incidence of legal errors has only been destined to move upwards. Physicians, whose core-concern being medical efficiency through best medical practices, cannot be expected of too much in this regard. Yet, because of it being integral to their practices’ sustenance and growth, its significance cannot be underestimated.

Notwithstanding physicians’ integrity in safeguarding medical information revealed by patients or discovered during the course of treatment, there have been instances of physicians running into legal issues on account of erroneous (though unintentionally) management of patient medical records. Irrespective of the intention, in view of adverse repercussions – severity of punishment ranging from civil charges (fines and suspension of practice) to criminal proceedings, including cancellation of practice license, and imprisonment – emanating from such erroneous management of patients’ medical information, it is advisable that physicians’ adhere to American Medical Association’s (AMA) ethical guidelines that govern the code of conduct on management of patient’s medical information; HIPAA guidelines are specifically formed and amended from time to time in this regard – the latest being the HIPAA 5010 scheduled to come into effect from October, 2013. Although AMA’s guidelines are not as legally binding as Federal or State-specific laws, yet – given the ethical nature of medical practice – judiciary has tended to being more approving of AMA’s guidelines. Therefore, physicians can deem AMA’s guidelines as the yardstick to measure their conduct of patients’ medical information.
Physicians can avoid committing the usual errors that have been identified over the years. Here are some of the frequent errors that physicians have tended to commit while handling patients’ medical information:

• Denying patients complete access to their medical records:
  Physicians have been reported to have presumed that their patients can be satisfied with partial access to their medical information. Though physicians have every right to withhold any information that may be damaging to a patients’ confidence or well-being, yet, in general cases, they should provide complete information as sought by their patients.
• Refusing to share a copy of the report with the patient:
  There have instances wherein Physicians have been summoned up by the law for refusing to share copies of medical reports with their respective patients. Therefore, it is a bounden duty of physicians to honor requests for copies of medical reports by their patients.
• Presuming that a non-custodial does not have a right to ask for a minor’s medical record: Proven wrong by the law (both Federal as well as State-specific), doctors should get rid of any such inhibitions as they might invite legal battles.
• Presuming HIPAA as the ultimate controller of patient information disclosure:
  Although HIPAA rules the roost in majority of cases, yet, there are areas where Federal and State-specific laws supersede HIPAA. Therefore, Physicians need to be mindful of parallel laws that work in tandem with HIPAA’s ethical guidelines for handling medical records.
• Honoring requests without being duly signed by the patients:
  Honoring requests of Data (PHI) sharing without being duly signed by patients can invite trouble if such requests happen to be unscrupulous. Therefore, physicians or their staff need to verify every request for patient signature, which is deemed authentic by Federal as well state-specific laws.
• Denying requests for records on account of unrealized fees from patients:
  While physicians have every right to realize their fees from patients, they cannot cite it as the reason for refusing request for records. Alternatively, they can only recover copying charges for such medical reports.
• Deeming it a right to charge patients for medical records:
  Although physicians have right to recover nominal fees for sharing copies of their patients medical records, they are not authorized to impose discretionary charges. At the most, they can include incidental charges such as postage and handling. The Federal as well as state-specific laws are very stringent on this. Therefore, physicians should avoid running into embarrassment for being unduly expensive.

Related Tags:California Medical Billing, Colorado Medical Billing


Despite such indicators from time to time, the incidence of legal errors has only been destined skywards. Physicians, whose core-concern being medical efficiency through best medical practices, cannot be expected of too much in this regard. Yet, because of it being integral to their practices’ sustenance and growth, its significance cannot be underestimated. Therefore, they need to source some kind of medico-legal advisory to mitigate the probability of committing errors in dealing with patient medical information.

With internal advisory proving either costly or ineffective, outsourcing seems to be the better option. Medicalbillersandcoders.com (www.medicalbillersandcoders.com), whose comprehensive medical billing management comes with a special feature dedicated to solve issues related to diverse situations in patient medical information handling, should offer physicians the much awaited respite from getting into legal tangle. The additional training to physician administrative staff and updates on billing and legal issues makes Medicalbillersandcoders.com the ideal platform for all physicians.

Alleviating the Time Factor in Evaluating Revenue Generation from Medical Claims

“While physicians would not mind investing in revenue optimizing systems, asking them to invest their invaluable time in something which is non-core to their medical efficiency could ultimately have an adverse impact on their efficiency for medical care. Therefore, there seems to be a considerable propensity to outsource Medical Billing Management”

The rapid healthcare reforms promulgated by the Federal Health Department have meant both unprecedented opportunities and threats for physicians across the United States. While the prospect of spiraling patient-base looms large, there also appears an element of apprehension over the effectiveness and efficiency with which they will be able to realize their medical claims amidst a reimbursement environment characterized by stringent audit-verifications. In fact, majority of physicians have expressed concern over unimpressive reimbursement rates despite investing heavily in compliant EHR, electronic billing and coding, and claim submission systems.

The bitter experiences have driven physicians to take stock of the situation, and evaluate their revenue generation from claim reimbursement against resource allocation. While physicians would not mind investing in revenue optimizing systems, asking them to invest their invaluable time in something which is non-core to their medical efficiency could ultimately have an adverse impact on their efficiency for medical care. Therefore, there seems to be a considerable propensity to outsource Medical Billing Management, which is believed not only to improve reimbursement rates, but also enhance the quality of medical care to patients.

Yet, amidst numerous service providers, the selection can often be tricky. Faced with such situation, physician should invariably conduct a SWOT Analysis of the shortlisted services providers for making judgment in favor of an apt service provider. Prior to soliciting a medical billing service provider, there is an underlying need to establish your service provider’s ability to provide comprehensive service package, comprising:

• Claim generation and submission
• Carrier follow-up
• Payment posting and processing
• Patient invoicing and support
• Collection agency transfer services

Further, you should also be able to figure out its ingenuity for amicable phasing of the billing management procedure – traversing a sequential pattern, such as credentialing, medical coding, transcription, insurance eligibility verification and appointment scheduling.


Additionally, the following criteria should usually form the basis for selecting a medical billing management company:

• Ability to provide highest level of service, which proves its capacity to pursuing denied claims, billing follow up, complying with regulations, and reporting and analysis of reimbursed claims.
• Substantial Industry experience, which validates its expertise in
• ICD9, CPT4 and HCPCS Coding
• Medical Terminology
• Insurance claims and billing, appeals and denials, fraud and abuse
• HIPAA and Office of Inspector General (OIG) Compliance
• Information and web technology
• Reimbursement
• Penchant for using the latest technological platforms, which verifies its sufficiency in EHR, billing software, coding technology, and online data repository service for data storage and dissemination across the network for interoperability.
• Pricing model adopted, which measures its flexibility to adopt result-oriented or project-based pricing systems.
• Receptive to new clients, which establishes its receptiveness to take on newer clients without any apprehensions.

Related Tags:Arizona Medical Billing, Arkanas Medical Billing

While these checklists are of immense utility to physicians seeking outsourced billing management solutions, the requisite comprehensive evaluation, yet again, involves time-factor of invaluable significance. Therefore, when faced with such daunting task involving intricate evaluation,

Medicalbillersandcoders.com (www.medicalbillersandcoders.com), whose comprehensive and proven Medical Billing Management – complete with accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards, should offer an easy recourse to instant selection.

Deciphering Medicare Fee Schedules

A proactive affinity to Medicare Fee Schedule alerts physicians to the efficacy of attending to Medicare beneficiaries, and also plans their revenue prospects in advance. But, with the legislation firm on mandatory medical service to Medicare patients, physicians are inevitably driven to seek and understand Medicare Fee Schedule.

The sheer volume of Medicare transactions (more than 50% of the total health insurance transactions in the US health insurance sector) is reason enough for physicians to understand the mechanism of Medicare payments from medical services provided to Medicare beneficiaries. Although the proposed inclusion of a substantial population into Medicare’s ambit should be a reason for celebration amongst practicing physicians, yet, the accompanying reforms that seek to economize and optimize Medicare payments should equally evoke anxiety among them. Therefore, given this unique situation of optimism and anxiety, physicians would be well-off with a proactive knowledge about Medicare Fee Schedule.

As Medicare Fee Schedule – which decides on the reimbursement to be allowed to Medicare providers for different services, and restricts the amount a non-Medicare provider could charge a Medicare patient – is the governing fee schedule promulgated by the Federal Legislation for both Medicare and non-Medicare providers, there is a growing significance of being knowledgeable about the likely reimbursement from attending to Medicare patients. Such proactive affinity to Medicare Fee Schedule alerts physicians to the efficacy of attending to Medicare beneficiaries, and also plans their revenue prospects in advance. However, with the legislation firm on mandatory medical service to Medicare patients, physicians are inevitably driven to seek and understand Medicare Fee Schedule.

Further, there are several prevailing factors that contribute to differential reimbursements to providers despite providing similar services under Medicare fee schedule. Usually, such cases can be found if the hospital is a teaching hospital, or if it cares for a disproportionate share of indigent patients, or if the facility is located in an area with a higher cost of living.

Amidst this complex Medicare Fee Schedule regimen, the following ready-reckoner released by the American Medical Association (AMA) should be comforting for physicians:

The current ready-reckoner works on the geographic adjustment provisions of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89), which requires all three components of the relative value for a service – physician work relative value units (RVUs), practice expense RVUs, and professional liability insurance (PLI) RVUs — to be adjusted by the corresponding GPCI for the locality. Effectively, the sweeping provision has increased the number of components in the payment schedule from three to the following six:

• Physician work RVUs: better known as Physician Work Relative Value Units
• Physician work GPCI: better known as Physician Work Geographical Practice Cost Index
• Practice expense RVUs: better known as Practice Expense Value Units
• Practice expense GPCI: better known as Practice Expense Geographical Practice Cost Index
• PLI RVUs: better known as Professional Liability Insurance Relative Value Units
• PLI GPCI: better known as Professional Liability Insurance Geographical Practice Cost Index

The comprehensive general formula for calculating Medicare payment amounts for 2011 is arithmetically expressed as:
Work RVU1 x Work (GPCI)2
+ Practice Expense (PE) RVU x PE GPCI
+ Malpractice (PLI) RVU x PLI GPCI
________________________________________
= Total RVU
x CY 2011 Conversion Factor of $33.9764
________________________________________
= Medicare Payment 

Related Tags :Albama Medical Billing,Alaska Medical Billing

But, given the intricacies involved in computing resultant payments, physicians would be hard-pressed for time and resource, which otherwise could be diverted to the most crucial aspect of their core services: keeping their medical efficiency benchmark improving. With the current dynamic changes in the healthcare scenario, the proven capabilities of Medicalbillersandcoders.com (www.medicalbillersandcoders.com), the largest consortium of medical billers and coders in the US, in imparting the crucial knowledge on Medicare Fee Schedule as part of its comprehensive Medical Billing Management is also an useful option for healthcare providers.

The Relevance of Using Perfect Modifiers in Medical Claims

The overlapping nature of certain medical procedures is such that it is impossible to report them with CPT codes alone. Although CPT coding has grown to be comprehensive enough to cover breakthrough procedures over the years, yet, physicians are not spared from submitting separate procedural forms for medical procedures requiring explanation that overshoot the CPT boundary. Recognizing a parallel system that not only obviates the necessity of submitting supplementary forms but also expedite the submission and realization of medical claims, American Medical Association (AMA) has long been known for promulgation of modifying those overlapping medical procedures through unique and efficient Modifiers, identified and approved for the very purpose of aiding physicians in successful submission and realization of medical claims for their medical services to the patient fraternity. Thus, physicians, having a unique recourse to their problems in medical billing, should be competent enough to not only know the definition of Modifiers but also the circumstances wherein they can apply them.

AMA defines Modifiers as codes that are used to “enhance or alter the description of a service or supply” under certain circumstances. From this definition, it can be inferred that modifiers provide the means by which the reporting physicians can indicate that services or procedures that have been performed have been altered by some specific circumstance but has not changed in its definition or code. Thus, modifiers can be attached along with the originally billed and coded forms, without being required to submit through separate forms. Further AMA has also identified the following circumstances that warrant the application of modifiers:

• a service or procedure which has both a professional and technical component
• a service or procedure which requires to be performed by more than one physician and/or in more than one location
• a service or procedure which has been increased or reduced
• a procedure wherein only part of a service is performed
• a procedure wherein an adjunctive service is performed
• a procedure wherein a bilateral procedure is performed
• a service or procedure which is provided more than once
• a procedure wherein rare events were witnessed

Having understood the circumstances and the extent to which modifiers can be applied during the course of preparing and submitting medical claims, physicians should also be conversant with the prevailing and acceptable modifiers that are unique to their individualistic practice specialties. Generally the following set of modifiers are frequently used and accepted by the insurance carriers:

• Modifier-25: needs to be attached with any evaluation management service done on the same day by the same physician. Further, the procedure needs to be beyond the usual preoperative and postoperative encounter.
• Modifier-24: can be used with any unrelated evaluation and management service by the same physician during postoperative period, and, like modifier 25, has no restriction as with the level of E/M code as long as it meets medical necessity. Also, all its components are time-based.
• Modifier-57: allowable when an evaluation and management service results in the initial decision to perform surgery.
• Modifier-50: allowable with bilateral procedure performed on the same day, during the same operative session, and on identical anatomical sites. Further, it can be used with add-on codes also; but cannot be used with procedures that are already described as bilateral procedures.
• Modifier-51: handy while reporting multiple procedures performed by the same physician on the same day. But, it can be clubbed with the procedure done on the same day by another physician.
• Modifier-59: necessitates reporting any distinct procedural service performed on the same day that is deemed apt under a medical situation. But, the physician needs to establish the need for such distinct or independent service while appending with the original procedure.
• Modifier-26: As certain procedures are combination of both professional and technical component, this modifier is useful while reporting the service as a professional component only.

Related Tags:Connecticut Medical Billing, Delaware Medical Billing

Although the Modifier System is comprehensive enough to mitigate all challenges while coding and submitting medical claims, the voluminous knowledge accompanying it would be hard to be digested by the physicians, who have a much more challenging task of keeping their medical practice benchmarks unblemished.

Fortunately, they can look forward to proven outsourced solutions on the horizon. Medicalbillersandcoders.com (www.medicalbillersandcoders.com), with a comprehensive outlook to their clients’ billing and coding management and with substantial hands-on experience across specialties, is uniquely poised to advise, own, and execute an efficient system of modification as part of its all-inclusive medical billing management.

Group Appointments: A new niche for Primary Care Practice

Group appointment, also referred to as shared medical appointment, includes multiple patients seen as a group for follow-up or routine care. These visits are voluntary for patients and provide a secure but interactive setting in which patients have:

• improved access to their physicians,
• the benefit of counseling with additional members of a health care team (such as a behaviorist, nutritionist, or health educator), and
• share experiences and advice with one another.

According to the AAFP, Group Appointments were utilized by around 6% of family physicians to provide some amount of patient care in 2005, and that number has gone up to 13% in 2010. Group medical appointments are also a key component of the patient-centered medical home (PCMH) model. There are three general models for the shared medical appointment:

• The cooperative health care clinic (CHCC), created for older patients requiring frequent, broad-spectrum care;
• The disease-specific CHCC, a diagnostically exclusive group that aids patients with chronic-disease management; and
• The drop-in group medical appointment (DIGMA), intended for established patients requiring a more comprehensive approach to their follow-up care.

Browse All: Medical Billing   Medical Biller and Coders


Medicare generally pays for group visits if there is some one-on-one time with the physician, but practices should contact local carriers and other insurers about their policies; some carriers are still resistant to the idea. 

Who benefits from this type of program?
Shared medical appointments can be satisfying to both the physician and the patient, used as substitution or in addition to a traditional appointment. They are most appropriate for patients requiring routine follow-up care, or frequent time with the physician, or chronic patients. They can offer an increase in the productivity and efficiency of the health care team as well as enhance the patient’s visit by offering a holistic and therapeutic approach. 

Staff
Group appointments might require trained staff to act as facilitators, or even especially experienced billers and coders who are able to understand the process of group appointments, in order to get proper reimbursement for the providers, although physicians can outsource billing assistance for such appointments to professionals who are trained and experienced in group practice billing.

Implementing an Ideal EMR System for Your Practice

“Judging from the evidences of successful EMR implementation, customization has been the pivotal element, and will hold good for future also. Taking cue from such references, practices can benefit immensely, and successfully mitigate the probability of misadventure”

More than the mandatory obligation of digitalizing/computerizing/electronically recording healthcare data, it is the overwhelming benefits over investment outlay that have convinced physicians, clinics, hospitals, and multi-specialty groups of the efficacy of implementing Electronic Medical Recording (EMR) in their practices. But, implementing the EMR systems that best serves your individualistic needs is not as easy as arriving at the decision to implement it. In fact, there have been instances of unsuccessfully implemented ventures at it. Therefore, presuming EMR to be universal, and leaving your EMR implementation to your vendor’s discretion could prove to be a costly error.

Judging from the evidences of successful implementation, customization has been the pivotal element, and will hold good for future also. Taking cue from such references, practices can benefit immensely, and successfully mitigate the probability of misadventure. The following pro-active approach should be a guiding light in the search of an effective and efficient Electronic Medical Recording System Implementation:

• Defining your needs:
  The first step to an effective and efficient EMR system is an internal analysis leading to a clear definition of your needs in terms of scope and volume of data capture. Such an internal analysis aids in preparing an amicable budget outlay for your individualistic EMR system implementation.
• Spelling out your hardware and software requirements:
  Having defined your needs, you should be able to clearly spell out your hardware and software requirements in line with your scope and volume of data capture needs. Doing so can cut out unnecessarily over-installing your capacity at an exorbitant cost.
• Short listing vendors: In a market characterized by vendor-oligopoly, selection becomes tricky. Therefore, it is desirable that you prune down the list depending on vendors’ relative credentials. Being an important exercise on the way to successful implementation, this can be crucial in avoiding a wrong choice of vendor.
• Arranging for demo: A preliminary demonstration of EMR Systems can reduce your apprehension over their capability. Therefore, it is advisable that you are presented with demos by short-listed vendors.
• Confirming on pre and post installation training: Mere installation would not serve your purpose comprehensively; ensuring proper orientation of your staff to the technology assumes greater significance. Therefore, your vendor should be able to provide for such orientation.
• The extent of post installation services: Like your vendor’s capability for providing pre and post installation orientation, their promise for extensive after-sales service is also an important consideration prior to choosing an EMR system for your practice.

The fore-play of these factors is likely to pose mounting challenges to physicians, who may lack the foresight on something that is not their core competence. Inevitably, they would need to seek out help from Medical Billing Management Service providers.

Medicalbillersandcoders.com, with a wealth of knowledge on advising medical fraternity with proven solutions in Medical Billing Management – technology interface for seamless reporting of medical data being one of their niche solutions – should be an ideal ally in helping to choose the best EMR System mapped to your unique needs, ensure your practice in congruence with Federal Healthcare Mandate for EMR, and even make your practices eligible for incentives for meeting the Best Practices in Electronic Medical Record System.

Hospitalists registered a pay increase in 2010

The year 2010 has registered a hike in the median compensation for Hospitalists. The Hospitalists in adult medicine saw their compensation increase 2.6% to $220,619 from $215,000 while the Pediatric Hospitalists’ pay rose by 7.2% to $171,617.


The report, which is based on MGMA survey information, takes into account data from 4,633 hospitalists in 412 groups and 726 academic hospitalists in 68 academic medicine practices. The pay also varied region-wise; the median compensation for southern hospitalists was higher as compared to west, Midwest and eastern region, that is, $235,701, $231,831, $211,751, and $205,000 respectively.


Browse All: Medical Billing   Medical Biller and Coders

 
One of the reasons for the hike in compensation is the increase in hospitalist productivity; hospitalists are being recognized for their value in other arenas, as it relates to the transition from the fee-for-service to pay-for-value-type models, championing effective transitions of care, leading process improvement teams, etc. Another reason for the rising trend in pay is the fact that the demand for hospitalists has exceeded the supply.
Another potentially significant variable that could strongly impact the future trends in the Hospitalists’ salary is the drastic healthcare reforms and regulations sweeping the industry.

Medicaid claims audits slated for January

The Medicaid recovery Audit program is due to get implemented nationwide in January, carrying on in a similar vein as Medicare RAC program, as announced by CMS on 14th September, 2011. The Medicare RAC had recovered $451.3 million in overpayments and corrected $78.5 million in underpayment within six months in 2011.

The Dept. of Health and Human Services estimates that Medicaid RACs will save the program $2.1 billion over the next five years, of which $900 million will revert to the states. The states must implement Medicaid RACs by Jan. 1, 2012, according to the final ruling.

The states will enter into a contract with the Medicaid RACs, which will review the past claims that have already been paid and scrutinize them for fraud, waste and abuse. The auditors will be recompensed by getting a percentage of the funds they recover as having been inappropriately paid to doctors, hospitals and others. However, AMA has indicated its discomfort over the fact that RACs will be paid on the basis of their recoveries.

At the same time, the final rule also directs states to pay reviewers for uncovering underpayments that must be reimbursed to those filing the claims.

Browse All: Medical Billing   Medical Biller and Coders 

The CMS has incorporated certain points in the Medicaid Audit program which were not present in the Medicare Audit program:

• Each Medicaid RAC must hire a physician as medical director
• The CMS has called upon the states to place a limit on the frequency and age of claims that Medicaid RACs can request from claimants for review
• Requiring states to coordinate their Medicaid RAC activities with those of other auditors; RACs cannot audit claims already being investigated by another entity
• Requiring RACs to return their fee if an overpayment determination is reversed at any level of appeal

The audit program is likely to aggravate the reimbursement as well as administrative burdens of the providers. Overall a need has been expressed for the CMS to take effective measures to educate providers as well as other health professionals to pre-empt inadvertent coding mistakes and the consequent incurring of penalties. In fact, these issues once again underscore the wisdom in utilizing trained and experienced billing and coding professionals well versed in handling RACs audits to pro-actively avoid auditor scrutiny.

How crucial will medical billers’ role be after healthcare reforms?

“Proactively realizing the need for preparing to face up to these challenges, many professional medical billing companies have taken up upgrading their system and human capabilities to the probable demands emanating from healthcare reforms”.

A string of healthcare reforms announced by the Federal Government over a year or so have changed the landscape of the healthcare industry nationally. The expected extension of insurance coverage for more than 30 million people, removing pre-existing condition clause, and an incentive based healthcare regime are going to influence and alter the equation for all the stakeholders concerned, more so the medical billing management companies/professionals. While the extensive coverage of health insurance should open avenues for more business and revenues, the ensuing stringent billing regimen – the mandatory EMR System Implementation, ICD-10and HIPAA 5010 compliant coding and reporting norms, and highly rigid insurance carriers – is going to test Medical Billers’ ability to adapt to the changing landscape. Never before has the role of medical billers been more debatable than now.

As the healthcare reforms take effect, Medical Billers will be called upon to redefine their role in as far as:

• Ensuring compliant EMR Systems for physicians: As a seamless EMR System is the foundation for apt medical coding, medical billers will be called upon to advice their clients’ on the efficacy of implementing EMR System as part of their effective and efficient medical billing management.

• Upgrading their competence to ICD-10 and HIPAA 5010: As the new coding and reporting regimen takes over shortly, medical billers – to avoid being outdated and obsolete – need to make a successful transition to the ensuing ICD-10 and HIPAA 5010 requirement.

• Helping physicians on public and private insurance composition: With the healthcare reforms deciding to minimize reimbursement on Medicaid and Medicare policies, physicians/hospitals are rethinking on what should be the composition of public and private insurance holders in their patient population. Consequently, medical billers’ role assumes greater significance in recommending a judicious mix of public and private health insurance holders in their clients’ patient population.

• Establishing a mutually respectable relationship with insurance carriers: Forging a cordial relationship can go a long way in ensuring fast, and delay free reimbursement of physcian’s medical bills; medical billers would do well to build a rapport with heterogeneous insurance carriers.

• Educating physicians about internal preparation for medical billing: Apart from ensuring a compliant system of billing, submission, and realization, medical billers will also be called upon to educate physicians about the efficacy of upgrading internal system of data recording and filing for complimenting comprehensive needs of medical billing management.

• Approaching Medical Billing as a wholesome exercise: Above all, medical billers will be asked to view physician’s medical billing from a complete revenue cycle management perspective rather than one-off billing exercises. Such a comprehensive approach improves the probability of positive outcomes immensely.

Proactively realizing the need for preparing to face up to these challenges, many professional medical billing companies have taken up upgrading their system and human capabilities to meet the probable demands emanating from healthcare reforms. Likewise, Medicalbillersandcoders.com – known for its proven medical billing solutions to a majority of physicians, hospitals, clinics, and multispecialty groups across the whole of U.S – has taken up advancing their system and human capability on a massive scale. With their vast hands-on experience on innumerable projects, and updated knowledge of healthcare regulations and IT, our MBC billers and coders bring a plethora of value-added services to enhance your processes and RCM.

Combating Healthcare Fraud and Abuse – a challenging task for providers

The inherent nature of Health Insurance is such that it is highly susceptible to fraud and abuse by unscrupulous healthcare providers and beneficiaries. Consequently, there has been an unbridled rate of fraud and abuse amounting to billions of dollars – a reliable statistics puts it around 300 billion dollars, and still counting. Whereas, primarily, it is a staggering erosion of Private and Federal Government’s Health Insurance Funds, it has wider repercussions: payers, employers and patients having to pay higher premiums, lower benefits, higher taxes and higher copayments on account of rising cost of health benefits, necessitated by unethical erosion of healthcare insurance funds.

While there have been regular reforms – medical billing and coding compliances such as EHR System, CPT coding regimen, and HIPAA compliant medical reporting, auditing programs – for checking this burgeoning problem, yet, insurance carriers are unable to shield themselves completely from this menace. The duality of this menace further compounds the issue:

Duality of Fraud and Abuse of Health Insurance Schemes
Fraud by Beneficiaries of Healthcare Providers Fraud by Healthcare Providers

• Using a member ID card that does not belong to that person
• Billing for services that were not provided
• Adding someone to a policy that is not eligible for coverage
• Duplicate submission of a claim for the same service
• Failing to remove someone from a policy when that person is no longer eligible
• Misrepresenting the service provided
• Doctor Shopping – visiting several doctors to obtain multiple prescriptions
• Upcoding – charging for a more complex or expensive service than was actually provided
• Billing for a covered service when the service actually provided was not covered

What is more alarming is that these dual entities have the propensity to collude and operate through an unholy nexus. Faced with such imminent threats, it is high time that health insurance providers implemented an effective program that can detect, investigate, prevent, prosecute, and recover the loss of corporate and customer assets resulting from fraudulent and abusive actions committed by providers, members, groups, brokers, and others. Although RAC audits have been able to recover a substantial amount of fraudulently claimed reimbursements, still, a considerable number of cases find ways to sneak in under their nose; the high cost of appointing Recovery Audit Contractors (RACs) – nearly ¼ of the total reimbursement to be audited for fraudulent realization – is not helping the cause either.

But, in the face of radical health care reforms – Affordable Care Organizations, proposed cuts to Medicare, and the negative impact of imminent Sustainable Growth Rate backlash – Federal Government’s Medicare and Medicaid – which account for a major share in the nation’s healthcare insurance scheme – along with major private insurance carriers, have the monumental task of safeguarding against adverse impact of health insurance frauds and abuse including higher premiums, lower benefits, higher taxes and higher copayments.

The scenario warrants these providers to either build or outsource proven anti-fraudulent measures that can ensure a profit-building model through raising premiums or adding new members. Such anti-fraudulent measures assume greater weight when they are faced with the undesirable prospect of erosion of their funds by 10% to frauds and abuse. With historical experience of internal anti-fraudulent measures leaving a lot to be desired for, recourse to proven agencies that have demonstrated optimum efficiency in anti-fraud measures and recovery rate is recommended.

Medicalbillersandcoders.com – having the distinction of being the largest medical billing consortium, and advisory to many insurance carriers – should be of immense help in this regard. With their exposure in billing and coding across specialties and payers, and expertise in all billing issues related to the latest compliances and regulations, their consultancy services can assist in scrutinizing inadvertent billing and book-keeping oversights, and pro-actively minimize compliance exposure by healthcare providers.