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Category Archives: Billing & Reimbursement

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HHS to Shift 90% of Fee-For Service Payments to Performance-Based Payments by 2018

Posted in Billing & Reimbursement, Health Reform, Medicare

Yesterday the Secretary of the Department of Health and Human Services (HHS) formally announced HHS’ intention to shift 90% of all traditional Medicare payments from fee-for-service (FFS) to quality or value-based payments by 2018. The secretary announced that HHS’ goal is to have 30% of traditional FFS payments tied to quality or value in 2016,… Continue Reading

CMS Issues FY2015 Medicare Physician Fee Schedule

Posted in Billing & Reimbursement, Medicare, Uncategorized

Last week, the Centers for Medicare and Medicaid Services (CMS) issued the final Physician Fee Schedule for Fiscal Year 2015.   The annual Physician Fee Schedule includes various policy and payment changes to be implemented in the coming year.  This year’s Fee Schedule includes details regarding Medicare’s payment for services outside of a face-to-face visit for managing the care… Continue Reading

Tips for Evaluating Provider Network Arrangements

Posted in Billing & Reimbursement, Practice Management, Reimbursement

In response to the development of alternative payment systems, provider networks are forming at a frenetic pace. If you are like most of my physician clients, you have been or will shortly be presented with network participation agreements for review (or in many cases, signature with very little opportunity to review) and consideration. In evaluating… Continue Reading

What Do Your Coding Statistics Say About You?

Posted in Billing & Reimbursement, Fraud and Abuse

One of the ways the Medicare program and other payer plans are recovering overpayments and identifying billing fraud is through the regular use of data mining.  Simply put, by utilizing software programs that monitor and compare billing and coding data, enforcement authorities are easily able to identify problematic trends in physician billing.  This is an extremely… Continue Reading

Advanced Imaging Suppliers To be Accredited by January 2012

Posted in Ancillary Services, Billing & Reimbursement, Medicare

Under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), all Medicare suppliers of the technical component of advanced imaging services have until by January 1, 2012 to become accredited by an accreditation organization designated by the Secretary of Health and Human Services . This includes physicians, non-physician practitioners, and physician and non-physician… Continue Reading

Medicare Eliminates Consult Codes

Posted in Billing & Reimbursement, Medicare

In case you missed it, the Centers for Medicare and Medicaid Services (CMS) eliminated use of the evaluation and management Consultation Codes.  Consultations are now to be billed using the standard E/M visit codes.  According to CMS Transmittal 1875: "Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment.… Continue Reading

Use the Correct Modifier When Billing for Diagnostic Tests

Posted in Billing & Reimbursement

According to a recent Transmittal from the Centers for Medicare and Medicaid Services, physicians and others are using modifier -PC to designate the "professional component" of diagnostic tests.  However, the -PC modifier is actually to be used to designate "Wrong Surgical or Other Invasive Procedure Performed on a Patient."  Apparently many providers assume that because… Continue Reading

Medicare Rules on Preventive Care Services

Posted in Billing & Reimbursement, Medicare

It is apparent that preventive care will take on greater importance in the "reformed " health care system and while Medicare historically did not cover routine or preventive screening services, the list of preventive services now covered by Medicare has grown in recent years.  Physicians should familiarize themselves with the applicable coverage and billing rules so… Continue Reading

Changes In Medicare Enrollment Rules

Posted in Billing & Reimbursement, Medicare

Physicians enrolling in the Medicare program should be aware that Medicare recently changed the rules applicable to when a physician’s enrollment is deemed to take effect. Specifically, the FY 2009 Medicare Physician Fee Schedule establishes that the effective date of billing for physicians and non-physician practitioners is the later of: (1) the date of filing of… Continue Reading

The Office of Inspector General (OIG) Releases FY2009 Workplan

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare

The Office of Inspector General (OIG) of the Dept of Health and Human Services released its FY2009 Workplan yesterday. The Workplan outlines the initiatives and audits that the OIG expects to undertake in the coming fiscal year.  Below are some of the key initiatives that the OIG expects to undertake with regard to physicians.  If… Continue Reading

Be On the Lookout for Better Educated Patients

Posted in Billing & Reimbursement, Practice Management

According to an article in the New York Times, Aetna will soon begin offering a new service to help enable patients to research their own specific medical conditions. Specifically, Aetna’s SmartSource Service will allow patients to link online research with their own medical records and claims data.  While a better patient educated patient population holds… Continue Reading

Medicare Changes Diagnostic Testing Rules and IDTF Rules

Posted in Billing & Reimbursement, Medicare

The much awaited 2008 Medicare Physician Fee Schedule has finally been formally published in the Federal Register (click here to read it).  The proposed Fee Schedule published in June of 2007, included a number of proposed changes to the Stark regulations as well as certain regulatory changes to the diagnostic testing rules and IDTF conditions… Continue Reading

New Jersey Department of Insurance Fines Aetna

Posted in Billing & Reimbursement

The New Jersey Department of Banking & Insurance has issued an order stopping Aetna’s practice of limiting non-participating physician reimbursement to 125% of Medicare.  The Department has also fined Aetna almost $10,000 for violations of state insurance laws.  Non-participating physicians in other states may find this development helpful in discussions with Aetna (or their insurance department, if necessary).   

A Recent Case on Physician Supervision of Incident-To Services

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare, Reimbursement

The Medicare incident-to rules permit a physician to bill for the services of auxiliary personnel as if the physician performed those services himself.  You may already know that the incident-to rules require a physician to be present in the office suite and immediately available to assist while auxiliary personnel are performing incident-to services in the office.  But,… Continue Reading