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Category Archives: Reimbursement

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Pay Attention to Non-Financial Terms in Managed Care Agreements Too

Posted in Physician Compensation, Practice Management, Reimbursement

Many physicians pay very little attention to their managed care participation agreements.  In fact, some simply sign these agreements without ever reading them.  I think this apathy stems from the fact that managed care plans generally refuse, at least for smaller practices, to “negotiate” their fee schedules.  But, even if a payor won’t negotiate fees,… Continue Reading

Take an Active Role in Defining Your Payer Relationships

Posted in Reimbursement

If you’re not sure what your managed care payers want from you, maybe you need to tell them. Many physicians are (understandably) complacent about taking an active role in defining in their payer relationships. Not surprisingly, managed care payers have had very little incentive or ability to negotiate special arrangements with a diverse and disintegrated… Continue Reading

Employed by a Hospital? Beware the New 3-Day Window Rule

Posted in Medicare, Reimbursement

Hospital-owned practices may take an unexpected hit in revenue under a new Medicare rule that bundles certain physician service fees into hospital payments. The so-called “payment window” rule (sometimes referred to as 3-day/1-day window rule) requires a hospital (or an entity that is wholly owned or wholly operated by the hospital) to include on the claim… Continue Reading

Medicare Physician Fee Reform May be on the Way

Posted in Medicare, Reimbursement

On November 24, 2009, the U.S. House of Representatives passed the Medicare Physician Payment Reform Act" (H.R. 3961) which would repeal the scheduled 21% fee reduction scheduled for January 2010.  The legislation would also permanently replace the existing Sustainable Growth Rate (SGR) formula with a new formula that, according to the House summary: Removes items such as drugs and… Continue Reading

No Long Term Fix for Medicare Physician Fee Cuts

Posted in Health Reform, Medicare, Reimbursement

Despite efforts by Senator Harry Reid to pass legislation which would have effectively frozen Medicare payment rates for physicians, it looks like Congress will once again look to freeze physician payment rates with a one-year patch. According to an article published by the Wall Street Journal, Senator Reid’s proposed bill would have permanently prevented Medicare… Continue Reading

Payors Looking to Better Manage Imaging Services

Posted in Reimbursement

According to a recent article published on AIS Health.com, Blues plans are increasingly turning to radiology management firms to help manage costly imaging services.  This is a new twist on the old "managed care" concept and, once adopted by the Blues, other major payors can be expected to follow.   Physicians who provide imaging services are well advised to monitor… Continue Reading

Geisinger Health System Offers 90 Day Warranty on Surgical Care

Posted in Reimbursement

Under what it is calling its Provencare program, Geisinger Health System is now offering patients what amounts to a ninety warranty on surgical care.  Under the program – something like capitation and use of clinical protocols - insurers are charged a flat fee for which patients receive unlimited follow up care after surgery.  Geisinger intends to control costs… Continue Reading

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

Pending PA Insurance Legislation Could Be Good News for Physicians

Posted in Pennsylvania Legislation, Reimbursement

Pending PA legislation would limit most insurance refund demands and retroactive payment denials by third party payors to a one-year lookback period except where fraud or miscoding occurs. The full text of the bill can be viewed here:physicianlaw.foxrothschild.com/HB2178P4462(1).pdf . The bill was passed by the House by a vote of 195 to 2 on June 30. It’s… Continue Reading