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Five Easy Steps to Provider Credentialing


Physician Credentialing Whether you are starting a new practice or simply adding a new doctor, you need to start the credentialing process atleast 3-6 months in advance before you plan to see patients. Here are five easy steps to get started -

1. Start the credentialing process early. Most credentialing can be completed within 3 months, but that doesn’t mean you should take that long, as complications can arise. Payers have recently been merging into larger organizations. As a result a practice's ability to expedite an application has diminished. You’re working on the payer’s internal timeline for application processing, so it makes sense to allow additional time for any difficulties that occur.   

2. Ensure that you application is complete. According to Joellen Scheid, an Anthem for Virginia credentialing manager, only 15 percent of applications are complete, while the rest are missing critical information required for processing. The most common areas of application deficits are missing data and obsolete data. Examples are:

  • Missing work history and current work status
  • Physician's practice and effective date with the practice
  • Hospital privileges and covering colleagues
  • Attestations
  • Malpractice insurance details

3. Update and attest with CAQH for quicker processing that is easier to access. The Coalition for Affordable Quality Healthcare started its uniform credentialing program about 15 years ago. Since then, most payers in the nation have adopted this program. Physicians who regularly update and attest with Coalition for Affordable Quality Healthcare find credentialing and re-credentialing much easier. The Universal Provider Data source is a part of CAQH's credentialing application database project. Its goal is to make provider credentialing more efficient for providers as well as for healthcare organizations. CAQH’s online database collects all provider information necessary for credentialing, with the goal of eliminating much of the administrative overhead, paperwork and errors that providers face during the process of credentialing.

Billing and insurance tasks contribute to a major portion of administrative costs for both providers and hospitals. Federally mandated CAQH CORE EFT and ERA Operating Rules also streamline and simplify provider payment and claim reconciliation.

4. Prepare for telemedicine credentialing. Some say telemedicine is the future of the healthcare industry. More than 36 million Americans have already used some form of it. It’s estimated that 70 percent of doctor visits can be handled over the phone — costing far less than an in person visit. The US military is one of the largest users, with about 55 percent of the Army's telehealth programs focused on behavior health.

When your goal is to provide widespread patient services in both rural and urban communities, you’ll be able to offer services to more people at lower cost with telehealth. But this type of credentialing can be especially tricky when granting privilege to practitioners for either first-time procedures or disaster service. More information about telehealth credentialing is available.

5. Abide by your state’s regulations. Each state has its own laws for timely credentialing, including in-state credentialing and reciprocity.  Your state Medical Group Management Association can help you ensure you are adhering to your state's standards and using them to your advantage. Your credentialing process will be easier when you gather all the information you need on new providers up front. State requirements are quite varied.  For example, in accordance with HCQA, NJ carriers must be willing to accept the NJ universal physician application form. Oregon’s universal credentialing application, created and maintained by the ACPCI eliminates the need to complete multiple unique applications for each health plan, hospital and insurer. Ironically, this state’s credentialing is not governed by the state. 

In short, compiling all the information well ahead of time and making certain that it is both accurate and complete will save you from delays and administrative nightmares that can delay your credentialing. Assembling your information to meet state, national and practice requirements and completing your documentation correctly the first time is likely to be the swiftest way to attain your goals.

10 Ways to Increase Medical Billing Profitibility
For more information about M-Scribe Billing Services please contact 888-727-4234.

How to Avoid Balance Billing Your Patients


Medical practices need to have procedures in place to lessen the risk of not being compensated for patient care. It's more than just checking insurance cards - that's but the eligibility verification starting point. That card's not a guarantee that the patient is covered for the visit and the related costs that may follow from it. Not only must the insurance coverage be verified, but also the patient's identity. 7 percent of all identity theft involves the fraudulent use of someone else's medical insurance card - a fast growing figure.

Verification of identity and coverage can be time consuming and costly, adding to the administrative burden of a practice. Yet to not do so is very risky. Providing services to a bogus patient creates an uncollectable debt, even should the impostor be arrested. Likewise, if it's later discovered a patient wasn't covered due to policy exclusion or limits, the patient may not be able to pay.

There are many automatic services available that simplify eligibility verification. The American Medical Association (AMA) estimates that eligibility verification costs $3.70 per patient when done manually, but only $0.74 when done electronically. Given that a single physician in the US has on average 1,200 patients, that's a savings of approximately $3,700 in annual savings in processing alone. The gain in having patients' eligibility and coverages properly verified is significantly higher. Some electronic verification systems also can check patients' financial responsibility history as part of the verification process. This enables practices to know who should be required to pay any balance due before walking out the door. The AMA notes that about half of the better performing practices are those that collection 90% of payments due before the patient leaves the office. Doing so also helps a practice lessen its use of third party billers, whose use only ads to administrate costs and lessens revenue - part of the 12% of "administrative excess" noted by Health Affairs.

Collecting at the time of service can also improve a practice's relationship with its bank. Banks often monitor a practice's debt levels and cash flow. Ideally, they see more money coming in from patients at time of service and a concomitant reduction in a practice's debt, note various consultants. If this isn't happening, it may affect a practice's banking relationship, especially when a line of credit's in place.

The simplest, least costly and most profitable solution to eligibility verification is having a system that performs automatic verification. 
Government funded insurance, such as Medicare and Medicare Tricare also have an array of automated systems available through vendors to verify patient eligibility. Some of these systems are now accessible through mobile devices, with at least one vendor providing verification access through an iTunes app. 

Avoiding Balance Billing
Balance billing issues are a large challenge for practitioners and patients, and a growing social policy issue. Obamacare's state exchanges and metal coverages (bronze, silver, gold) are bringing millions of unsophisticated medical insurance consumers into practices across the land. Many believe that their insurance coverages are as stated in their policy and that all services are so covered. They may not realize this isn't true only when they receive a huge balance billing statement, which they can't or won't pay. 

When referring a patient to a colleague, Obamacare insured or not, it's prudent to first determine if that practice accepts that patient's medical insurance. It only takes a moment and can reap dividends: Medical bankruptcy is the primary cause of personal bankruptcy in the US. If your patient walks into a balance billing scenario, referred by you, he may just angrily walk on all his medical bills. Help your patient, help yourself, by confirming eligibility before making the referral.

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Top 5 Medical Claim Denials in Medical Billing


Family and internal medicine denials

In the shifting seas of medical claims billing requirements, the general categories for claims denial are reasonably stable. We thought it might be helpful to review some of the major ones. Some are simple, some are impacted by the changing landscape of government mandates in general and the ACA (Obamacare) in particular:

1. Noncovered charges
2. Coding errors
3. Overlapping Claims
4. Duplicate claims
5. Expired time limit

Noncovered and Excluded Charges: Marketplace Plans

The Essential Mandates portion of the ACA governs all levels of the marketplace metal plans: Bronze, Silver, Gold and Platinum. Despite the publicity surrounding the conversion of marketplace coverages from private insurers to the various insurance exchanges, Excluded Charges are overall proving remarkably stable from year to year. 80% of the top ten of them remained unchanged from 2013 to 2014, according to an analysis by HealthPocket, which surveyed data from 3,094 health plans in the 2014 individual family health insurance market

The private health plans replaced by ACA metal plans mostly covered essential services such as office visits, tests, ER care, and hospitalization and therefore these services don’t appear among excluded items. Maternity care (Prenatal and postnatal care), though not covered by 81% of private plans, ranked 15th among uncovered services in 2013, so it isn’t reflected in 2014 ten top listing for the ACA’s marketplace plans.)

The attempt at consistency in the marketplace plans at the federal level isn’t reflected in the state exchanges, where the coverage of some services excluded by the federal plans by illustrates the current fragmented nature of marketplace coverages. 20 states’ exchanges cover infertility treatments, for example. Only by being conversant with the marketplace insurance coverage provisions of their individual states can practitioners know what services are covered.

1. Noncovered Charges: Medicare

Medicare is at least consistent and not subject to the coverage vagaries of the individual insurance marketplace. CMS states clearly what it pays for and what it doesn’t pay.

Medicare-covered services are those services considered medically reasonable and necessary to the overall diagnosis or treatment of the beneficiary’s condition or to improve the functioning of a malformed body member.

The claims payment issues with Medicare lie not in what it covers for, but in the claims process itself, notably the ICD-9 ICD-10 diagnostic code conversion mandate, which is touched on below.

2. Coding Errors in General

Claims edit functions ensure that claims data submitted to a payer are correct. If it not, the claim is returned unpaid. Attributes that are verified include format, allowable values, required presence and data integrity. This processes determines whether or not the claim was properly coded by the provider.

The AMA issues an annual National Health Insurer Report Card that details claims accuracy and the costs of inaccuracy. Medical practices spent 14% of their income on ensuring that they’re paid. Claims returned to practices for “rework” i.e., error correction, by the top 7 commercial insurers in 2013 cost practices an average of $2.28 per claim to correct, with 10.7% of all claims returned for rework. The AMA study didn’t address ICD codes specifically, instead defining all Medicare claims submissions as “CMS,” which could include both ICD and CPT codes. (CMS Publication 100-04).

3. Duplicate Claims

A duplicate claim is one that’s resubmitted for a single encounter on the same date, by the same provider, for the same beneficiary, for the same service or item. It’s denied as a duplicate with error code CO18. Duplicates are one of the largest reasons for Medicare Part B claim denials, According to Government Accountability Office (GAO) study its as much as 32%. CMS notes, however, that claims rejected as duplicates may be valid claims for payment, if the correct condition codes or modifiers are applied to demonstrate a claim isn’t really a duplicate.

4. Overlapping Claims

Not as straightforward as a duplicate claim, CMS defines an overlap as occurring: “... when the date of service or billing period of one claim seems to conflict with the date on another claim, indicating that one of the claims may be incorrect.” Some codes that can indicate an overlapping has occurred are:

N347: Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer

M86: Service denied because payment already made for same/similar procedure within set time frame may be incorrect.

Overlaps require some research to resolve, especially when other provider’s involved.

5. Expired Time Limit

Some practices hold smaller claims and batch processes them later—sometimes too much later. All insurers have time limits on claims submissions. Medicare requires all claims be filed within 12 months following the date of service. Its rules as noted below do allow three possible areas of exception:

  • Administrative Error: failure to meet a filing deadline caused by error or misrepresentation of an employee, the Medicare contractor, or agent. In these instances, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider, or supplier received notice that an error or misrepresentation was corrected.
  • Retroactive Medicare Entitlement: Occurs when a beneficiary receives notification of retroactive Medicare entitlement to on or before the date the service was furnished. In such cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider, or supplier received notification of the retroactive Medicare entitlement.
  • Retroactive Medicare Entitlement Involving State Medicaid Agencies: where a State Medicaid Agency recoups payment from a provider or supplier six months or more after the date the service was furnished to a dually eligible beneficiary. In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which a State Medicaid Agency recovered the Medicaid payment from a provider or supplier.
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Five simple steps to streamline your medical billing process


Medical Billing stategiesMedical billing service is perhaps the most important administrative tasks a doctor's office or medical facility has to contend with on a regular basis. One of the challenges facing administrative staff is the increasingly complex and ever-evolving laws and regulations surrounding medical billing service.

In order to keep the office running smoothly in light of these developments, it is important to make the medical billing process as efficient and streamlined as possible. The following are a few suggestions on how to make that happen. 

1. Make sure all patients sign all relevant medical forms

One of the biggest headaches that can occur during the medical billing process is having a claim rejected or delayed due to missing patient signatures. Creating a standard process through which front office staff can get every necessary patient signature before they leave the office can save a significant amount of time and difficulty later on. 

2. Have a dedicated staff member for medical billing

Properly medical billing requires a significant attention to detail. Constantly being interrupted by other office tasks or by incoming and outgoing patients can cause distractions that lead to mistakes. If possible, try to have one staff member whose sole responsibility during a particular period of time is taking care of all medical billing and coding. Since this can be fairly monotonous if it is their sole job, offices are probably better off giving the responsibility in shifts, say one morning or one afternoon per staff member per week. Bureau of Labor Statistics estimates that the medical billing industry as a whole will increase in 2015 as well. In fact, it is estimated that the industry will grow by about 22% between 2012 and 2022.

Outsourcing medical billing service entirely is also a good option for various reasons explained here.

3. Have a standard process for following through on delinquent claims

Allowing delinquent claims to pile up can have a significant impact on the revenue and overall cash flow of a doctor's office. Implementing a standard process through which all delinquent claims are handled can save time and ensure that all claims are being paid on time. For some offices, this means outsourcing medical billing to a third party. For those who are unwilling or unable to take that step, software that helps handle delinquent claims can be very helpful.

4. Use technology and software whenever possible 

This is similar to the suggestion above, but a bit more general. Computers, tablets, and software can save a doctor's office a lot of the time they would otherwise be spending on medical billing. When used properly, technology and software can reduce the number of human errors that are possible, and take some of the burden off of administrative staff. One essential key to using technology is making sure that the administrative staff knows how to use it properly, as there are few things worse than having hundreds of patent files incorrectly generated.

5. Have all relevant patient data 

This suggestion is good for more than just efficient billing, it is just a general best practice for medical offices overall. Today, patients have much more relevant data than simply their insurance provider, phone number, and physical address. Incorporating information such as email addresses, preferred method and time of contact, and other data can help ensure that the relationship between the doctor and patient is as efficient and hassle-free as possible. This is beneficial for the office because it increases the likelihood that they will be able to contact the patient about important information in as timely a fashion as possible. It is also beneficial for the patient, as they also appreciate being contacted in the self-selected method that they prefer. At the same time, however, it is imperative that every doctor's office ensures that they are complying with HIPPA and any other relevant regulations, particularly the ones regarding privacy. 

    Efficient medical billing is more important than ever before. Fortunately, with some foresight, it is possible to make an office efficient without completely changing the way things are done within it, so that everyone can focus on what is most important: providing best possible patient care!

    For more information about M-Scribe Billing Services please contact 888-727-4234.

    Improper E/M coding leads to loss of revenue for practices


    Improper E/M coding leads to loss of revenue for practicesIt is no secret that E/M claims, also known as Evaluation and Management claims, have been causing major problems for the medical industry over the past several years. According to a study by the Department of Health and Human Services, as much as $6.7 billion was inappropriately paid in 2010. That amounted to 21% of Medicare payments and a staggering 42% of incorrectly coded claims. In fact, the $6.7 billion that was inappropriately paid disguises the extent of the problem, due to the fact that the incorrect coding included both upcoding and downcoding, with the majority of incorrect claims being downcoded.

    How improper E/M coding affects the medical practices

    Evaluation and Management (E/M) miscoding is expensive for the entire medical industry. Not only is Medicare paying out billions more than they should, but doctor’s offices and other medical facilities that are downcoding are losing out on revenue that they are legally entitled to as well. While many of the downcodings are in fact mistakes, a significant number of them are entered deliberately by doctors who want to counteract the upcoding they presume (or know) has also been entered on their behalf.

    Improper E/M coding can be broken into two major categories. The first is due to upcoding, which ultimately costs Medicare billions of dollars on higher fees. This in turn impacts the long-term viability and solvency of the entire program, and burdens taxpayers and other parties within the medical industry unfairly. While some of this improper upcoding is done purposefully, a great deal of it is simply the result of administrative mistakes or a lack of appropriate knowledge in medical offices.

    The other major problem with improper E/M coding occurs when doctor’s offices and medical facilities accidentally downcode their billing reports. Much like improper E/M upcoding, this results misallocated revenue, however in this instance it is the doctor’s office or medical facility that suffers the consequences. Although downcoding does not cost Medicare additional revenue, it does result in a loss of revenue for the medical facilities themselves, many of which are already dealing with shrinking margins as it is.

    Solving the problem of improper E/M Coding

    According to the Department of Health and Human Services, there are already mechanisms being put into place to counter improper E/M coding. With the cost already in the billions of dollars, and with such a large percentage of medical facilities and doctor’s offices committing these mistakes, Medicare contractors are starting to focus on E/M coding and documentation, particularly among doctors who have a high percentage of their billings as E/M billings.

    Industry leaders are also recommending that doctors begin the practice of self-audits on their own offices. In addition to hopefully reducing the number of E/M errors, this practice can also ensure that the office is billing properly and in full compliance with the relevant regulations. In addition, for offices that have been inadvertently downcoding, there is the possibility of increased revenue from the correction of improperly coded E/M claims. However, even if a particular office finds that it is actually upcoding, this can still be a financial benefit to the office, as it prevents the possibility of expensive legal action; it is also of course the right things to do.

    In addition to the recommendations by the Department of Health and Human Services listed above, doctors and medical offices should also learn to document their patient encounters more accurately and in more detail. This can help in the self-auditing process and is also a smart best practice to utilize in general.

    E/M claims are an important part of the medical industry, and in particular for doctors whose patients are on Medicare. With the problem of improperly coded E/M claims rising rapidly, now is the time to make sure that your own office is in order. Utilizing M-Scribe’s medical billing and coding services is one of the best ways to ensure that your office is complying with and properly coding E/M claims. Their services will give you the peace of mind you need to run your practice effectively. For more information about how M-Scribe E/M billing and coding services can help you, please visit M-Scribe E/M coding services. 

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    Increase Revenue By Avoiding Common Medical Coding Mistakes


    common coding mistakeWith the first year of full Obamacare implementation nearing its end, doctor's offices and healthcare facilities are still working on streamlining all of the new administrative and regulatory rules and requirements that the law imposes. While medical coding mistakes are nothing new, now it is even more important to prevent them from occurring, since the administrative delays and insurance company hold-ups they cause can have even more of a significant impact. Although there are plenty of possible medical coding and billing mistakes, the following are a few of the most common and most important to avoid.

    Illegible handwritten claim forms

    It might seem unbelievable in today's age of technology and computers, but there are still numerous medical coding mistakes that occur simply because they are handwritten in such a way that they are misread and mis-entered into the system. One of the best ways to avoid this is to simply ensure that all medical coding and billing is done using a computer and a printer. With more than adequate printers available for less than $100, there is simply no reason for any medical facility, no matter how small, to still be using any handwritten forms.

    Certified coders help medical billing and increase revenue.

    Failing to add necessary modifiers

    Modifiers are more important today, with the implementation of the Affordable Care Act (also known as Obamacare) than ever before. Failing to add necessary modifiers will often lead to delays in payment, and can sometimes even lead to an outright refusal for payment to be made. While there are many important modifiers to keep in mind, one of the most important times to use one is when a healthcare facility performed multiple services in a single patient visit. Modifier 25 is used specifically for this situation, as it helps differentiate a "significant, separately identifiable evaluation…service by the same physician…or other service." Failing toutilize Modifier 25 can lead to significant delays in payment by insurance companies, and administrative staff in a medical facility should always make sure they are checking for cases in which Modifier 25 is applicable. Linking medical necessity codes to treatment codes Insurance companies have long been sticklers about having a documented medical need anytime a procedure is performed. One of the ways that insurance companies attempt to get out of reimbursing a medical facility for services rendered is by claiming that the procedure was not properly linked to a medical need. It is more important than ever before for doctors to properly document their patients' medical issues, so that when treatments are performed, they can easily be linked to without any hassles from the insurance company. One of the other important considerations is making the diagnosis codes are specific as possible. For example, hypertension is coded as 401, but that coding will almost always result in a claim denial by an insurance company. It is absolutely imperative that any and all diagnosis codes include the maximum number of code specifics. In the case of hypertension, this involves adding a period and an addition number. Malignant hypertension, for example, is coded as 401.0, while benign essential hypertension would be coded as 401.1. It is important to specify these differences not only to avoid hassles with insurance companies, but also to ensure that the proper treatments are given to the patient. While many medical administrative staff members are familiar with the importance of properly coding claims, it is always worth spending sometime refreshing one's knowledge so that as few mistakes as possible are made. This will save everyone involved time, frustration, and unnecessary hassle.

    Accurate medical coding is a critical component of any medical practice, and is at the heart of the practice billing process. Without proper coding, a practice can lose considerable amounts of money and may even face fines and penalties when codes are repeatedly used incorrectly.

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    Benefits of Outsourcing Medical Billing Services


    Outsourcing Medical BillingOutsourcing your medical billing and coding to an experienced professional organization has a variety of benefits.

    "Patient privacy" is a big buzzword in the medical field these days, with a number of countries including the United States putting medical professionals under strict legislation to guarantee patient privacy protection. With compliance more crucial than ever, medical facilities now have the added work and responsibility of ensuring their organizations comply with the stringent regulations. 

    This adds up to a large number of additional considerations medical professionals are now required to stay on top of on a daily basis. Is everyone in your organization up to speed on all of these privacy considerations? This is one of the primary reasons to outsource your medical billing, coding and documentation to an experienced professional organization who can make sure you're always fully compliant with patient privacy considerations and regulations. 

    Industry Experience and Adaptation 
    The best medical billing and coding services are firmly rooted in and informed by the medical field. They are in tune with what medical professionals and organizations need and provide it in an efficient, intuitive and thorough manner. Experience counts, but so does the ongoing flexibility to stay in touch with the latest industry trends and technologies so that services can always be provided in the easiest, best and most economical ways possible.

    Professional medical billing and coding company helps to simplify potentially overwhelming tasks for medical organizations, staff and patients. Cutting-edge technologies and processes assist medical organizations and facilities in taking care of medical billing and coding while also staying in compliance with relevant privacy regulations. Staff can then manage larger document loads, and patients appreciate the easy and rapid accessibility to their records. Coding audits and pre-RAC auditing services help to ensure your ongoing patient privacy compliance. Other benefits of outsourcing your medical billing and coding to an experienced professional include: 

    Practice Management (PM) and EHR Adoption
    Your outsourced medical billing and coding team will be prepared to work with your EHR and PM right away. They do not take time to learn new system because of their experience but in case of in-house employees it takes painfully long to train and sometime they become indispensable for this very same reason.

    ICD-10 refers to the 10th modification of the International Classification of Diseases. Physicians, medical providers, clinics and private practices must change the code they currently use to record and document symptoms, diagnoses and procedures to comply with the new system by 2015. A medical billing and coding expert will be up to speed on these changes, allowing you to keep this consideration off your list of things to do. 

    Faster Payments 
    The accurate, compliant, and timely return of your organization's documentation will conveniently expedite and in some cases increase your revenue because of efficient coding denials will be minimal, claims will be cleaner.

    Attentive Customer Support 
    Instead of having to go it alone and navigate your way through billing, coding and documentation snafus, you'll have access to 24/7 customer support to take care of it for you. That way, you can spend more time seeing patients instead of buried in documentation. 

    Streamline Your and Operations and Workflow 
    Documents handled include patient documents, medical publications and other multimedia resources. Optimized search and retrieval tools can be seamlessly integrated into your existing office system. Existing documents (including EOBs, and other billing related paperwork) can be scanned and organized into a secure system and even be accessed from mobile devices from anywhere in your facility. With admin outsourced, staff members can focus more on providing outstanding patient care. 

    Paperless Option 
    A paperless digital option can help to streamline your process even further. Organization, patient privacy, and ensuring client satisfaction are all facilitated with outsourced medical billing and coding services. Digital documentation means less of your own storage space is needed and you'll be able to reduce costs spent on office supplies such as toner and paper. 

    Accuracy and efficiency are crucial in the medical field. With a well-established core team of over 500 healthcare professionals assisting over 25 hospitals and 200 clinics in the U.S., M-Scribe is ready to bring all of the benefits of outsourced medical billing and coding to your facility.

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    How Obamacare will impact medical billing in 2015?


    Obamacare and Medical BillingIt's now been over four years since the Affordable Care Act, otherwise known as "Obamacare", officially went into effect in the United States. However, we are just now learning the wide-ranging impacts the legislation has had on the healthcare industry, and in particular on medical billing in hospitals and doctor's offices throughout the country. While we still don't know the scope of changes that are yet to occur, there are some undeniable trends that seem to be making their way down the pipeline, particularly as we prepare for the oft-mentioned "employee mandate", which, if all goes according to the (often revised) plan, goes into effect in 2015. 

    Medical Billing Will Increasingly Become Outsourced 
    Medical billing has never been a particularly popular activity in doctor's offices and in hospitals. Now, with the increasing number of medical coding requirements resulting from the Affordable Care Act, medical professionals are continuing the trend of outsourcing this work to companies that specialize in it. According to a report in Seeking Alpha, large outsourcing companies such as Firstsource Solutions and WNS are increasing their domestic US presence to accommodate a growing number of medical professionals who are choosing to outsource medical billing to them. 
    By 2015, more doctors and hospitals are projected to outsource their medical billing than ever before, in large part thanks to Obamacare and growing administrative costs. The other less discussed (but no less important) consideration is that outsourcing medical billing reduces liability on the hospital or doctor's office. 

    The Number of Medical Billing Professionals Will Grow Dramatically 
    While outsourcing is certain to increase in 2015, The Bureau of Labor Statistics estimates that the medical billing industry as a whole will increase in 2015 as well. In fact, it is estimated that the industry will grow by about 22% between 2012 and 2022. While some of this increase is in fact due to regulatory and administrative burdens resulting from the Affordable Care Act, many experts also believe that the changes from the ACA will actually reduce administrative issues, increase efficiency, and ultimately grow the medical billing industry at a slower rate than it otherwise would have in the absence of the Affordable Care Act. 
    The other key reason why the medical billing profession is expected to grow is the simple fact that, under the Affordable Care Act, more people will have access to healthcare, which means more medical coding and medical billing will be required. While increased access to healthcare for the overall population (and particularly the poor) is a worthy goal, it comes at the very real cost of increased administrative and regulatory issues, at least in the short-term. 

    Precertification and Eligibility Verification Will Continue to be Cumbersome 
    While it's true that one of the original promises of the Affordable Care Act was reduced difficulty for hospitals and doctor's offices that needed to pre-certify or verify eligibility of a patient for a particular procedure, reality has proven itself to be more complicated. Early reports indicate that, at best, this process is as slow and cumbersome as it has always been, while critics claim that it is in fact less efficient than before the ACA was passed into law. Part of the problem stems from the fact that many insurance companies and medical offices still aren't even sure how to properly code procedures and medical services; a problem that, while severe, should hopefully improve gradually in 2015 and onward if all goes well. 

    Obamacare is causing significant changes in the medical billing industry. Hopefully the negative aspects will diminish over time, while the promised benefits of the law start to take hold. 

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    Stage 2 Meaningful Use Explained


    Stage 2 Meaningful UseThe meaningful use of electronic health records refers to the use of EHRs in ways that healthcare providers can measure qualitatively and quantitatively. The United States government has enacted legislation that will roll out requirements for the meaningful of EHRs in three stages, from 2011 to 2016. Stage 2 is scheduled to become effective in the near future, and will impose additional requirements for healthcare providers who wish to qualify as meaningful users.


    The Health Information Technology for Economic and Clinical Health(HITECH) Act of 2009 describes the intended benefits of this act. They include an improvement in the general health of the population in the United States and in increase the security and privacy of health information for patients. The HITECH Act will also engage patients in their healthcare and reduce disparities in healthcare among patients of different economic means. It will also improve the coordination of patient care between healthcare providers.

    The Obama Administration plans to use financial incentives to promote the use of EHRs. These include incentives for software developers who obtain certification for EHR software, which will ensure that this software meets specified quality standards. The incentives will also enforce open standards for EHR software to ensure that software vendors and users have the same goals.


    The U.S. Department of Health and Human Services provides specific criteria for meaningful use in each of the three stages. Stage 1 was implemented from 2011 to 2012 and deals with data capture and sharing. Stage 2 will be implemented in 2014 and will deal with advanced clinical processes. Stage 3 is scheduled to be implemented in 2016 and will address improved outcomes for patients.

    Stage 2 will require health information exchange to become more rigorous. It will also increase the requirements for prescribing medication through electronic means, commonly known as e-prescribing. Stage 2 will incorporate the use of lab results into the criteria for meaningful use. The transmission of patient care summaries will also be addressed in Stage 2, as will additional data that is controlled by patients.


    The Centers for Medicare & Medicaid Services (CMS) describes the objectives of meaningful use for each stage, which consists of core objectives and menu objectives. Stage 2 introduces a new set of objectives, most of which are menu objectives. Many of these objectives provide exceptions that allow healthcare providers to qualify as meaningful users without meeting objectives that fall outside the scope of the provider’s clinical practice.

    Eligible healthcare professionals who wish to qualify as meaningful users under Stage 2 must meet all 17 of their core objectives and three out of six menu objectives for a total of 20 objectives. Eligible hospitals are required to meet all 16 of their core objectives and three out of six menu objectives for a total of 19 objectives.

    Some objectives are common to both healthcare professionals and hospitals, while others are different. For example, both groups must use computerized provider order entry to order laboratory test, medication, and radiology tests. Both groups must also record demographic information for a patient such as gender, race, ethnicity, date of birth and preferred language. Additional requirements for both groups include recording the patient's vital signs such as height, weight body mass index. They must also record the blood pressure for patients older than three years and smoking status of patients older than 13 years.

    Objectives that are different between hospitals and healthcare professionals include the requirement of hospitals to provide patients the lemon aerie cause of death. Hospitals must also perform medical reconciliation when transferring a patient between settings under certain circumstances.

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    Benefits Of PQRS Enrollment for Group Practices (GPs)


    PQRS benefitsThe traditional fee-for-service model is quickly giving way to a new and exciting healthcare standard. The Physician Quality Reporting System (PQRS) has proven instrumental in this transition, offering the financial incentives necessary to convince medical professionals to ditch their usual approach to healthcare. Under PQRS, Eligible Professionals (EPs), are promised significant incentives in exchange for their commitment to prompt reporting of necessary information. Issues related to PQRS eligibility have left many interested parties confused since the program's adoption, with members of group practices especially curious about their standing. It is possible for group practices to take advantage of PQRS, but they must first meet a handful of stipulations. Once these conditions are achieved, approved group practices enjoy access to incentive payments similar to those available to individual EPs. 

    Benefits Of PQRS Enrollment 
    PQRS holds obvious benefits for isolated EPs, many of whom may otherwise struggle to get by in the current economic climate. But group practices also stand to benefit from PQRS enrollment, assuming they abide by the strict rules for reporting. For an approved group practice, the reward for satisfactory reporting is an incentive payment amounting to a selected percentage of the practice's estimated Medicare Part B Physician Fee Schedule charges. In addition to the basic monetary incentives, group practices participating in PQRS are able to improve their standard of care, while preparing for future reporting challenges in the rapidly-changing world of healthcare. 

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    PQRS Enrollment Requirements For Group Practices 
    In order to qualify for PQRS incentives, group practices must agree to a number of stipulations, including the posting of measured PQRS performance on the Physician Compare website and the willingness to comply with secure data submission practices. Additionally, participating group practices must already possess the needed technological specifications for the program, including the presence of Microsoft Access and Microsoft Office. 
    Although group size does not determine whether a particular practice is eligible for PQRS incentives, practices are required to disclose this information while enrolling for the program. The sizing categories for PQRS include 2-24 EPs, 25-99 EPS and over 100 EPs. 

    Reporting Systems For Group Practices 
    While enrolling for PQRS, each group practice is required to select a preferred reporting system. Group practices tend to be better equipped for a variety of reporting systems than single EPs, so a greater measure of consideration may need to be applied to this important decision. Many group practices prefer to utilize Group Practice Reporting Option (GRPO) web interfaces, as these may also satisfy requirements for the Medicare Electronic Health Reporting Incentive Program. In order to take advantage of the web interface option, a group practice must include over 25 EPs.

    Group practices lacking efficient EHR setups often opt for PQRS Registry Reporting. A new and increasingly popular option involves the Centers for Medicare and Medicaid Services (CMS) Certified Survey Vendor, which allows for reporting through the CG CAHPS survey. As with the online interface, the CMS Certified Survey Vendor option is only open to practices with 25 or more EPs. 

    The pay-for-performance healthcare option is increasingly becoming the preferred approach among a variety of group practices, meaning that, in the near future, the usual fee-for-service method may no longer be the standard for healthcare billing. PQRS is currently ushering in this new age of performance-based payments, opening up the incentive program to a variety of group practices. Although participating practices must content with sometimes complicated reporting stipulations, they are rewarded with significant financial incentives and quite possibly, a better standard of patient care. 

    Getting Started with PQRS

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