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Category Archives: Reimbursement

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What is the Medicare Quality Payment Program and How May It Affect My Practice?

Posted in Billing & Reimbursement, Medicare, Practice Management, Reimbursement

There are big changes coming to the Medicare incentive programs as we know them.  Beginning on January 1, 2017, the new Quality Payment Program (the “Program”) will replace all existing Medicare incentive programs with a comprehensive incentive model.  The Program will involve a modified set of EHR Meaningful Use requirements, new quality of care metrics,… Continue Reading

CMS Finally Makes Reasonable Changes to 60-Day Overpayment Rule

Posted in Billing & Reimbursement, Fraud and Abuse, Health Reform, Medicare, Physician Compensation, Practice Management, Reimbursement

The Affordable Care Act (ACA) requires Medicare providers to return overpayments within 60 days of the date they are identified in order to avoid liability under the False Claims Act.  Four years ago, CMS issued a proposed rule to implement this statutory requirement that would have placed a substantial burden on providers to identify and… Continue Reading

Offering Discounts (or Waivers) of Coinsurance/Copayments to Patients as an Out-of-Network Provider

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

Commercial payors are actively looking for ways to reduce payments to out-of-network providers.  One area of focus is discounts and waivers of patient copayments and deductibles by out-of-network providers.  In the eyes of these payors, coinsurance/copayments are essential to incentivizing patients to use in-network providers, and discounts on (or waivers of) coinsurance/copayments by out-of-network providers… Continue Reading

New Study Suggests Defensive Medicine May Be Effective in Reducing Malpractice Liability

Posted in Billing & Reimbursement, Health Reform, Malpractice Insurance, Practice Management, Reimbursement

A new study in the BMJ suggests that the more services a physician provides to his or her patients, the less likely the physician is to be sued for malpractice.  The study examined the use of resources by attending physicians in several Florida acute care hospitals during a ten-year period from 2000-2009, in relation to… Continue Reading

The Switch to ICD-10

Posted in Billing & Reimbursement, Health Reform, Medicare, Practice Management, Reimbursement

The long-anticipated implementation of ICD-10 coding finally began this past Thursday, October 1, 2015.  As of that date, government and commercial payors ceased to accept claims under the old coding system (ICD-9).  The transition has been five years in the making due to a government delay in 2012. The new system has five times the… Continue Reading

First Court Decision on the Medicare/Medicaid 60-day Overpayment Rule

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

You may have heard some years ago that the Affordable Care Act established a “60-day overpayment rule” that requires a provider to report and return any overpayment from a federal health care program (such as Medicare or Medicaid) within 60 days of “the date on which the overpayment was identified” by the provider (for certain… Continue Reading

Expanded Authority for CMS to Deny Enrollment and Revoke Medicare Billing Privileges

Posted in Articles, Billing & Reimbursement, Medicare, Practice Management, Reimbursement

You may have heard that CMS recently expanded its authority to deny enrollment and revoke the Medicare billing privileges of providers and suppliers.  The new changes could affect any physician, group practice or other Medicare provider or supplier.  As the changes are wide reaching, all Medicare providers and suppliers, and anyone providing support services for… Continue Reading

Pennsylvania Senate Bill would Limit Retroactive Denials

Posted in Pennsylvania Legislation, Reimbursement

These days, more often than not, physicians and up on the short end of the stick when it comes to new health care legislation. However, last month a bill was introduced by Senator David Argall which, if passed, would give physicians and other healthcare providers important protection against retroactive insurance denials. Specifically, Senate Bill No.… 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

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