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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-Ready 
    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.

    Overview

    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.

    Schedule

    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.

    Criteria

    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. 

    Join our free webinar on Aug 20th, 2014 to know more about how to get incentives or prevent 2% Medicare Penalty. Register Here!

    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. 

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    Medical Coding For Preventative Care and Diagnostic Services

      
      
      


    preventive vs diagnostic careThe Affordable Care Act aka Obamacare ensures access to free preventative measures, allowing medical professionals to catch medical issues before they become severe, or better yet, to prevent them from developing in the first place. In order to accomplish this lofty aim, patients are encouraged to schedule regular checkups, at which preventive measures such as screenings and vaccinations may be pursued. Many of these services are offered at minimal cost or are completely covered by insurance plans. 


    Although prevention and diagnosis often are lumped into the same category, they describe completely disparate types of medical care with different coverage options and payment plans. The two may occasionally experience some overlap, such as when a medical issue is highlighted during a preventative screening. Even then, medical billing procedure separates the preventative screening from any further tests used to obtain a diagnosis. 

    Preventative Care 
    The goal of preventative care is to maintain a reasonable baseline of health, so as to reduce the likelihood of major diseases and conditions in the future. Often, this means encouraging activities and behaviors that will result in better health outcomes. Preventative measures can also be used to detect medical issues for which, due to heredity and other factors, patients may be susceptible. Patients cannot be charged copays or coinsurance for the following preventative measures: 

    • Blood pressure screening

    • Cholesterol screening

    • Depression screening 

    • HIV screening 

    • Diet counseling 

    • Cessation intervention for tobacco users 

    • Type 2 diabetes screening 

    • Mammograms and breast cancer prevention 

    A number of vaccines are also covered under the preventative care stipulations in the Affordable Care Act, including hepatitis A and B, tetanus, human papillomavirus (HPV) and diphtheria, among others. 

    If other medical issues are noted during medical screenings, ensuing care may be covered under preventative coding and billing in certain situations. However, in most situations, everything that occurs after the screening will be coded as diagnostic. 

    Diagnostic Services 
    Preventative screenings often alert physicians to major medical problems, which, following the screening, may require further examination. Any tests or procedures conducted during this process may be deemed diagnostic for purposes of medical billing. The main exception involves preventative colonoscopy screenings; if a polyp is discovered and removed during the same visit, the entire procedure is coded as preventative. 

    A great deal of confusion stems from tests that, depending on the patient's reason for scheduling an appointment, could be considered preventative or diagnostic. Mammograms are particularly apt to cause confusion; when used as a screening tool, they are deemed preventative and thus, fully covered by insurers. But for patients visiting due to lumps or pain, the screening may be coded as diagnostic. 

    Coding For Preventative And Diagnostic Services 
    Medical coding for preventative and diagnostic care can be complex, particularly if both types of care take place during the same visit. Preventative services should be marked with the appropriate CPT codes, with additional designation required for measures considered preventative only when pursued by Medicare members. If diagnostic services are required during a prevention-based visit, the medical coder can include the appropriate E&M diagnostic codes with the preventative encounter. The same procedure may be considered preventative or diagnostic depending on the circumstances of the visit, so it is important to thoroughly document all patient data collected during the encounter.

    M-Scribe Coding Services

    Due to the complicated nature of preventative and diagnostic billing, many clinics and practices choose to avoid payment issues by offering patients documents that cover the differences in medical coding procedure for preventative and diagnostic services. Patients are encouraged to read and sign these documents before receiving medical care. Even with the presence of disclaimers, some degree of confusion among patients is to be expected. 

      10 Ways to Increase Medical Billing Profitibility

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

    Will Obamacare increase personal medical bankruptcies?

      
      
      


    obamacareDespite its rocky rollout it’s clear now that Obamacare is succeeding in bringing medical insurance to many of America’s uninsured. According to a recent Gallup poll, the uninsured rate fell to 13.4 percent in the second quarter of 2014. It peaked at 18 percent in the 3rd quarter of 2013. This is the lowest quarterly figure since Gallup started tracking medical insurance enrollments in 2008. The Commonwealth Fund reports that as of May 1, 2014, 20 million people now have coverage under the Affordable Care Act. The largest number of enrollees, 8 million, purchased insurance directly through government run health insurance marketplaces, 6 million through Medicaid or CHIPS, 5 million from an insurer, and the remaining 1 million young adults under 26 enrolled in their parents’ plans. This is a remarkable success, especially given that 20 states are still firmly set against extending Obamacare to their Medicaid recipients.

    At this point we can expect to see the uncharted shoals of Obamacare begin to emerge. For example, common wisdom is that the often comparably low monthly premium covers all, after the usual clearly stated deductibles, exclusions and coinsurance. This isn’t true, of course: the ACA isn’t National Health. It’s a pastiche woven from compromise.

    Many of those freshly enrolled in Obamacare are newcomers to the medical insurance arena and are unaware of coverage pitfalls. Nowhere is this more dramatically clear than when balance billing issues arise. In balance billing, providers charge patients the full market rate for services. This often occurs because the patient, unbeknown to him or her, has been treated by a practitioner outside of the patient’s insurance network, be it PPO, HMO, or, increasingly an EPO. The New York Times last year chronicled the financial catastrophe that can befall patients and their families when balance billing comes into play. “It’s not uncommon for patients who visit an in-network hospital to learn later that they’ve been treated by out-of-network providers, resulting in thousands of dollars in charges,” notes the article, “Out of Network, Not by Choice, and Facing Huge Health Bills.”

    Under Obamacare, as with traditional plans, patients referred by their in-network practitioners to a specialist who’s not in their network can end up with huge unforeseen bills. Likewise, in-hospital services are often provided by physicians unknown to patients or even unseen by them, such as anesthesiologists, radiologists, pathologists. Overwhelming bills can come from them, to.

    The ACA does make some provision for balance billing in emergency services, but otherwise not, notes The Times. “It is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do,” said health care law expert Professor Timothy S. Jost.

    Evidence is emerging that Prof. Jost is correct. Obamacare seems to be sparking the growth of EPO’s—Exclusive Provider Organizations—into which insurance carriers are moving Obamacare enrollees. EPOs typically have fewer participating providers and offer less coverage. California’s Anthem Blue Cross is facing a potential class action suit over what The Los Angeles Times tagged as “more litigation over narrow networks in Obamacare coverage.” Anthem’s Obamacare subscribers allege they were surreptitiously moved from Blue Cross PPO’s into EPOs, and so inappropriately subjected to balance billing. Some of the Obamacare enrollees had prior PPO coverage, and believed they still did.

    We’re seeing millions of new, unsophisticated medical services’ consumers coming into the marketplace through Obamacare enrollment. Most are largely unaware of medical billing nuances, such as balance billing. It’s possible over the next few years that because of this we’ll see an increase in medical bankruptcies. Studies of Obamacare’s forerunner, Massachusetts’s Romneycare, showed that medical bankruptcies in that state were largely unaffected by Romneycare. In 2007-09, medical bills “contributed to 52.9% of all bankruptcies in the state. Absolute numbers of medical bankruptcies were up by a third,” reported The American Journal of Medicine.

    One out of three Americans have trouble paying their medical bills. Medical bankruptcies constitute 62% of personal bankruptcies in the US. Most medical bankrupts “were well educated, owned homes, and had middle class occupations. Three quarters had health insurance,” according to the Kaiser Family Foundation.

    Unless and until the Obamacare legislation is modified to account for all aspects of balance billing, medical bankruptcies will rise if not soar.

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