If a patient with a Medicare Advantage Plan sees a physician out-of-network, coverage will be determined by their health plan, and most plans do not have out of network coverage.
For the Physicians, regardless of coverage, the maximum that can be charged to a Medicare beneficiary is the Medicare fee. Even if the patient does not have coverage and the physician is not participating with the Medicare Advantage Plan.
This protection also extends to Medicare eligible, but not enrolled patients, who are covered under the Federal Employee Health Benefit Plan or their spouses. The maximum that can be charged to the patient is the Medicare limiting charge.
If the Physician is participating, or non-par, taking or not taking assignment, the maximum that can be charged is the Medicare fee. The only exception is if the physician has withdrawn from Medicare, and has the patient sign an acknowledgement.
At Medcare MSO we make sure that our clients have true projection of payments and reimbursements. If you have any question regarding your patient class and community. Call us today at 800-640-6409 and schedule an appointment with one of our billing support specialists.
Electronic Health Records (EHR) and Electronic Medical Records (EMR) often come with software to “advise” you about coding. This advisory software is promoted as increasing your revenue by advising you that if you document more, you can increase your CPT to a higher level. If you document completely, your level 3 visit can become a 4, or even a 5.
In reality, the services provided must be appropriate for the diagnosis given. Level 4 and 5 billings will readily be identified and should be expected to be challenged. Don’t assume that your automated code advisor with your electronic medical records software will have eliminated these challenges. If the diagnosis does not fit, the CPT code is declared excessive.
Somewhere in the documentation of your software is a disclaimer that explains that their code advisor is simple advising, the determination of the appropriateness of coding, and the responsibility-liability-for the actual coding remains the physicians’ responsibility. Watch the diagnosis as well.
The level of services provided must also be commensurate with the diagnosis under treatment. While all the requirements of a level of care may be fully and completed documented, does the diagnosis under treatment warrant the level of service? Increasingly payers are using computerized models to compare CPT codes with the diagnosis codes and identify patterns of what they allege to be excessive services for the diagnosis listed. For Example an ear infection in an otherwise healthy patient would be difficult to justify level 5 E/M, even if the level 5 were fully documented according to the documentation standards.
At Medcare we make sure that codes are compliant to the level of care and AMI regulations. To become a client or schedule a demonstration, please reach us at 800-640-6409.
Are you a healthcare provider that is looking to bring the latest technology and efficiencies to your practice? At Medcare MSO, we are helping medical groups achieve performance standards that result in increased practice revenues.
Pay for performance is a term used to describe a health care payment system that rewards health care providers, medical doctors and hospitals when they provide high quality service with minimal cost.
As part of the Health Care Reform Act, the federal government has now been implementing pay for performance in the Medicare program. At this preliminary stage, it is not yet clear how effective the program has been at maintaining and reducing healthcare costs.
There is a new system in place that rewards providers for focusing on preventive care rather than treatment. It will reward doctors for practicing and implementing care treatment that has been proven to improve health outcomes and provides incentives for doing so.
- The biggest challenge in implementing pay for performance is to get a consensus on quality standards. For example, one of the measures under consideration is the minimal time of treatment received by the patient. Observation and care co-ordination is not always dependent upon the service delivery by the provider. Other factors can be the type of facility where the patient is admitted and in what condition the patient was in. Moreover, achieving pay for performance is not possible without the help of a professional billing service like Medcare MSO where our teams work behind the scene and monitor all of your quality measures. We make sure that your practice is in compliance with all of the requirements to ensure you receive the performance incentives.
Medcare MSO is a complete revenue cycle management company that provides EMR, PMS and medical billing services. We are experienced in over 25 medical specialties and institutional practices. We have clients across the U.S., and we strive to provide innovative solutions to your practice.
One of the most critical issues for providers is the timely filling limits of insurance companies, which have been constantly shortened in recent years.p>
Payers seem to be looking for ways to make the payment process more difficult. Medicare has changed their policy to not allow any claims over 12 months to be eligible for submission. In response to this problem, many practice management systems have developed a timely filing monitoring function. These solutions provide an automatic alert to follow up on the claim and even bill/re-bill in advance of filing deadlines.
The best practice for any medical billing service is to follow up on completed practice claims within 45 days and to make sure no claims are un-paid in 30+ aging. While following up on the claims, payers with low timely filing and slow payment history should be followed up first.
Ideally, all practices should be aware of their practice payer mix and the number of days left for critical filing. Some insurance company rates vary according to the dates of submission.
There are several payers which offer the opportunity for providers to submit claims after the timely filing period. Such payers require a special timely filing indicator that justifies the late filing. An appropriate delay reason code helps to prevent a payment reduction on the claim.
To find out how our experts can help with late claims from filing issues, please call 800-640-6409 xt 1 and schedule an appointment with one of our technical support specialists.
Medicare Fraud is constantly showing up as a topic in the news. It’s difficult to say how much money is lost every year. Do you know what the typical types of Medicare fraud are?
Here are three of the most common cases.
Phantom Billing: In this instance, medical providers bill Medicare for procedures and unnecessary services that were never performed, or for equipment and supplies that have already been used. Such cases are often discovered by the government upon review of the paper work and medical records.
Patient Billing: When a patient collaborates with a doctor, he/she provides the insurance information to the health care provider which they use to bill Medicare as a scam. The patient is often paid a part of the proceeds and is legally at risk for this activity.
Up coding and Un Bundling: Up coding and Un Bundling is the most common type of Medicare Fraud where provider offices might not be aware of having broken the law. In this scenario, services codes are up-coded to show and get reimbursed for higher collected amounts. It also involves claim of services that are bundled with the primary procedure with an inappropriate or erroneous use of a modifier.
The penalties for Medicare fraud are outlined in the Federal Sentencing Guidelines and HHS program. The Inspector General for the U.S. Department of Health and Human Services under Public Law mandate 95-452 protects Medicare and Medicaid fraud. HHS department works in close collaboration with Federal Bureau of investigation to prevent Medicare Fraud. Defendants can expect to have jail for a substantial amount of time, compensations, fines and possible deportation if not a US citizen.
At Medcare MSO we make sure that our client’s bills are legitimate and they are following the right steps to meet all of the standards and regulations. To find out more about Medicare fraud and abuse please call us today at 800-640-6409
Lately many health care providers have been complaining about an un-justified level of E/M Billing. The physician community thinks that there is actually more time consumed in reviewing the patient’s past medical history in counseling and in an evaluation in a face to face encounter then claimed in CPT: 99213 level III E/M Code most frequently used by all physician and practices.
Quit often medical billers and providers confuse the coding guidelines for 99213 when it says that 2 out of three key components must be required. (Setting apart the time consumed.) Those component are:-
• Detailed problem focused history.
• Detailed examination.
• Low complexity medical decision making.
Physician practices often lose collections when the key components are missing and when under estimating the time consumed in delivering services. For a citation, a patient appeared back in an office with results on diagnostic tests. The physician didn’t have a detailed medical history review or a detailed examination. The actual face to face encounter lasted more than 20 minutes while counseling the patient on the reports outcome, medication dosage guidance and symptomatic counseling. If the total face to face encounter lasted more than 20 minutes the physician could still claim Level IV CPT: 99214
This slight adjustment after a proper review of your patient encounters and health records can increase the collections from $15 to $20 per service. If an average increase of $18.00 is realized from correcting under coding, this can increase revenues by $95,000 per annum to a practice seeing 20 patients a day.
With proper EMR and practice management tools, the efficiency in offices can be greatly improved. Analyzing encounters and coding can uncover many opportunities. We often find that an analysis of these procedures is time well spent. The expertise that comes from state of the art coding tools and constant updating of software can make a difference.
At Medcare MSO we make every possible effort to find out more ways to increase the revenue streams of our clients. We make sure that your codes are compliant with current laws and you are getting reimbursed for what you truly deserve.
To learn more please sign up for our free practice analysis. Find out if your coding is in compliance and if you are getting full reimbursement for services delivered.
As eminent from the name Medicare Fraud is basically being guilty with Medicare or being involved in abusive Medicare payments. It’s difficult to say how much money is lost every year under the Medicare fraud but do you actually know how many different types of Medicare frauds there are?
Medicare fraud is typically of three types each one of them is given below;
Phantom Billing: In this type of Medicare Fraud, medical providers bill Medicare for procedures and unnecessary services that were never performed equipments and supplies that have already been used. Such frauds can be caught up by the Govt. upon review the paper work and medical records.
Patient Billing: Under such fraud patient is involved with the doctor, he/she provides the insurance information to the health care provider which they use to bill Medicare as a scam. Patient is paid on part of scam money and admits to any service upon any follow up or investigation until proven.
Up coding and Un Bundling: Up coding and Un Bundling is the most common type of Medicare Fraud which provider offices might not be aware of that they are involved in. Under this abuse services codes are up-coded to show and get reimbursed for higher money and reimbursements. It also involves claim of services that are bundled with the primary procedure with an un-appropriate or erroneous use of modifier
If found guilty? Fraudulent party would have to face strong penalties according to Federal Sentencing Guidelines and HHS program. The Inspector General for the U.S. Department of Health and Human Services under Public Law mandate 95-452 protects Medicare and Medicaid fraud. HHS department works in close collaboration with Federal Bureau of investigation to prevent Medicare Fraud.
Defendants can expect to have jail for a substantial amount of time, compensations, fines and deportation from country if not a US citizen.
At Medcare MSO we make sure that our client’s bills are legitimate and they are following the right steps to meet all of the standards and regulations. To find out more about Medicare fraud and abuse please call us today at 800-640-6409.
Why is the United States so far behind most western countries in implementing the use of Electronic Medical Records (EMR). The US is nearly 20 years behind in this technology. Most other industry segments have invested heavily in technology, and reaped the benefits in time and cost savings.
There are many reasons why the US healthcare system has fallen behind. What are they?
Doctors are not tech savvy
EMR changes much of how a healthcare facility operates. How all of the daily functions flow and are tracked will be revamped. Many physicians are not comfortable with technology, and they might have to rely on the advice and expertise of others to implement EMR software systems. Having experienced trouble with previous systems and implementations is a common problem. Physicians are often stretched too thin to see their way clear to allocating the time and resources to getting the process started and completed. Office staff that have been following a familiar system also resist the effort and confusion a new system can bring.
Too many choices?
There are hundreds of EMR solutions on the market. Making the right choice takes a lot of time and investigation. It is important to select a solution that can be customized to fit your practice. This is important for workflow management, and the cost of this customization should be thoroughly checked out when buying a product. It is also important to find out how much support the vendor will provide when implementing the system. There are horror stories in the market where software arrives and then users are left to fend for themselves. Instead of creating efficiencies, many roll outs create time loss and frustration.
In an ever fast paced electronic world, bells and whistles in a software program may not be the answer. Find out what you really need and what efficiencies can be realistically gained. Measure productivity costs if you can. Once you feel comfortable with the answers you get from an EMR provider, take a deep breath and move forward. It may take some time to realize the benefits, but they will come. Your return on investment (ROI) should not be too difficult to calculate. Your vendor should have studies available. Look them over and see if they make sense to you. Calculate your practice hours and the efficiencies that you can realize. A good choice here can mean excellent rates of returns and the opportunity to grow without having to substantially add to the staff.
Always take the time to see if the vendor has references with practice similar to yours. A few call to the sources can give you valuable insight into what you will face as part of the process. Usually a fellow practitioner will give insight you can’t get from anywhere else.
These days many health care providers and groups are looking to find unique ways to get better reimbursements for their services.
One interesting development that has emerged in the industry is to have a Dual Aspect in the healthcare practice. Basically; dual aspect refers to having two practices at the same location operating under two different NPI and Tax IDs. The key point in setting up two different practices is to be participating and non-participating with payers at the same time.
M J Baba, MD a pulmonologist in Houston, TX has been working under the dual aspect policy for some time now. He operates two different practices under the same location named as Clear Lake Pulmonary (Participating Group) and Clear Lake Hospitalist (Non-participating Group)
The practice sees all of its PPO clients under Clear Lake Hospitalist, resulting in more reimbursements processed at reasonable and customary fee rather than just being paid at the flat contracted rate. Dr Baba’s practice has had some great success after the implementation of this policy which generates more money with the same amount of time and service delivery.
This small single provider practice and the method they have followed was successful to the point that they now employ over 10 health care providers. Getting the most out of billing procedures is a must in today’s competitive environment
“The experience working under the dual aspect has been phenomenal, now we don’t have to worry about lower reimbursements tracking and having to deal with tough follow ups after that. Under some indemnity plan, reimbursements went up from $60.00 to $90.00” said Dr Baba.
Medcare MSO makes every effort to do research and bring up on what’s trending in the industry. We make sure that our clients benefit from our in depth market analysis. To find out more how we can help your practice, call 1-800-640-6409 and schedule for a free demo
As with most major changes in any industry, the big businesses are the first to implement new technologies and electronic health records (EHR) are no exception. Hospitals and large clinics have been using EHR for some time now. Perhaps it’s time for you to look at introducing new medical software into your practices to streamline billing and coding and bring your medical billing into the digital age. Here are just a few of the benefits of the EHR system.
Access to Information
When you consider all the time and energy spent on getting information from other practitioners and labs, it is easy to see where it would benefit you to have a shortcut. Lab results can be available as soon as they are passed by the QA department in the lab. Patients’ histories are already there when you need them.
Another benefit of getting information this way is that the increased speed makes your patients happy! They don’t have to wait as long for lab results, and in many cases, can access the results themselves which saves your staff the time of taking the call, finding the right person and gathering the info as well as talking on the phone to the patient.
Save Time Spent on Medical Billing
Your staff has a lot to do and if they are billing and coding repeatedly and then also dealing with confusions and errors in the entries, you wind up paying for a lot of lost time. With medical software designed to streamline right into the EHR format, you save the hassle and the cost that would otherwise be incurred.
Your Data Is Safe
Paper records can not only be lost or misplaced, but you can lose the whole collection in a fire or flood. When your billing and coding records are in the EHR system, they are digital and can easily be backed up in several places, so that even if your server is destroyed, a current version is being held elsewhere.