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Nursing facilities across the U.S. have somehow endured a series of Medicare/Medicaid cuts thus far, but the latest move by CMS to reduce reimbursement for so-called Medicare “bad debt” – Medicare co-payments not made by beneficiaries or state Medicaid programs – may bring them on the threshold of a major operational crisis.
Multiple strategies will be required by medical practices to cope with an anticipated drop in productivity due to ICD-10. Coding, claims processing, case management, decision support and follow-up (electronic medical billing system) are likely to face greatest impact due to the new system
Amongst the possible reasons for denials, coding inadequacies seem to have a major impact. Because codes quantify and qualify physicians’ medical services for medical reimbursements from payers, any inherent coding error, miscoding, over or under-coding can lead to denials upon found to be incongruent with acceptable coding practices. While a few coding manipulations may happen intentionally, most of the time it is the complexities of coding that often expose physicians or their staff to coding errors. With revisions made to CPT and HCPCS Level II codes every year, coding-related complexities are destined to multiply further. Failure to discern and apply revised coding systems may eventually result in disqualification or outright Denial of Physicians’ claims. As a result, physicians may have to forgo a considerable chunk of their revenues in the absence of remedial measures.
With many of the healthcare reforms set to take effect shortly or having already been in force, providers may have entered a different phase of operational model, which is called value-based model. The unique feature of value-based model is that providers will get reimbursed for delivering superior medical care at a progressively lesser cost. As the public plans such as Medicare, Medicaid, and most of the commercial plans are likely to adopt value-based reimbursement models, it may be inevitable for providers to shift over or find a balance between fee-for-service model and value-based model in order to sustain profitable clinical practices.
To being with, you have Medicare's value-based payment modifier that will be launched for physicians in groups of 100 or more in 2015. The unique thing about this modified value-based payment model is that it works on the principle of ‘carrot and stick’ theory, meaning physicians may either be eligible for either positive or negative payment adjustment depending on their level of compliance with care quality and reporting. To prepare for the eventual 2015 model, it may even be necessary to demonstrate capability for PQRS reporting, beginning as early as 2013. Furthermore, the performance post 2015 will be significant as most of the value-based returns will start yielding from 2017 based on the PQRS reporting post 2015.
Why most practices are unable to collect maximized revenue?
Time constraints to regularly track - 1st time claims, denied claims and underpaymentsTime restraints to manage a varied payer mixIncreased administrative burdens, staff challenges and poor revenue visibilityHealthcare reforms, industry changes and regulationsIncreased patient demands results in less time to manage the billing process optimally
EMH Healthcare Improves Critical Test Results Communications with Amcom ...MarketWatchFor all other wet readings, the ER doctors would then have to retrieve information from the PACS [picture archiving and communications system] and reenter it into...
This year’s CPT Manual has spelt out extensive coding changes and revisions to orthopedic surgical codes. In all, there are 500 code changes to the Category I codes, including 251 revisions, 151 new codes and 100 deletions. Moreover, there has been significant overhauling of nerve conduction studies, some revisions to the radiology section, and E/M changes. The extent of these coding changes and revisions, having already taken effect from January 1, 2013, has begun to impact orthopedic reimbursements in a big way. As a result, orthopedic practices may have inherited an ominous task of migrating to a higher order in orthopedic surgical coding. Given the CPT Manual’s full list of revisions, deletions, and additions to have been effected for 2013, orthopedic practices would require to be conversant with the guidelines for the following coding sections:
Contrary to the notion that government’s move to digitize healthcare information would enable healthcare providers, doctors, and insurance companies comply more aptly with HIPAA’s guidelines for patients’ privacy and security, there has been an upsurge in HIPAA breaches with providers being reported for breaches of some kind or the other. Electronic Health Record (EHR) systems, which are made mandatory for providers seeking to attain ‘Meaningful Use’ status, have shown propensity to be manipulated either internally or by unscrupulous external elements. Either way, providers have been held accountable and penalized for breach of HIPAA’s mandate for ensuring patients’ information safety and security. With the cost data breaches being unbearable and providers or doctors’ credibility at stake, it is inevitable that HIPAA breaches are responded instantly with remedial measures, such as:
In 2010, Medicare improper payment amounted to $47.9 billion. Human and Health Services, in 2011, recovered $4.1 billion paid through reimbursements as a result of ‘fraudulent’ or ‘improper’ claims. You may be right if you think you won’t ever be among the fraudulent care practitioners who contributed to these figures because you are scrupulous. But being scrupulous can’t prevent you from being suspected by federal authorities, thanks to the profusion of fraudulent cases – because bizarrely all some care providers have had to do to attract the scrutiny of federal authorities is over use a billing code, regardless of whether they did it for right or wrong reasons.
Radiology collections, which have been far from being impressive in the recent years, may further go down amidst a host of issues likely to surface throughout 2013. Significant of those issues is the reimbursement cuts, which is supposed to lead to a reduction of almost 19% in the collections of radiology practices. Further, a 25% cut in payments for imaging services has not gone down well with providers, who may eventually be discouraged to comply and continue with revised guidelines.
Podiatry is specific to the procedures for toe, ankle or foot treatments, so the medical billing and coding is a specialized process with detailed and specific codes. It also carries very precise guidelines and policies for the procedure to be billed. Your Podiatry practice cannot ignore the rapid changes and updates in the codes or will suffer from incomplete claims, decreased revenues and possible audits. It requires the transition to ICD-10 coding as well as the varied codes for a wide range of medical and surgical procedures. A compliant billing and coding Podiatry Practice must keep in mind –
Find In- house biller for a Chiropractic practice in Washington jobs in Seattle , Washington , US. Apply In- house biller for a Chiropractic practice in Washington jobs at Medical billers and coder.
Andersen Keen's insight:
Must possess previous experience in billing and reimbursement proceduresConversant with Chiropractic, Acupuncture, Physical Therapy & Massage Therapy billingRequires to be familiar with Chirotouch practice management softwareShould be able to review medical charts accurately and assign appropriate codesMust ensure all assigned codes meet insurance and insurance regulationsPossess significant billing experience to help reclaim funds and reduce rejections Follow-up until payments are received and resubmit denied claimsPossess significant billing experience to help reclaim funds and reduce rejections Required to research/analyze accounts to determine payment patternsMust be detail-oriented, organized and able to maintain a high degree of accuracy
How Clinics Can Leverage Social Media: Being an Online Shaman For a long while it was felt that the medical profession was one way or another prisoner to the so-called Parkinson’s Law, proposed by the scholar of public administration Northcote Parkinson...
Insurance underpayments continues to be a major concern for medical practices across the United States; more so for orthopedic surgeons, who, despite serving in a more critical specialty, find it hard to fully recover their medical cost. Because most of the orthopedic procedures happen to be highly expensive, even a marginal percentage of insurance underpayments might turn out to be a major drain on practitioners’ revenue, which could severely spoil clinical and operational efficiency. With orthopedic surgeons’ insurance underpayments touching an all-time high of 10 percent and potentiality to reach 20 percent, it may be time that orthopedic surgeons relooked at their medical billing practices and process, and aggressively track and resolve their underpayments. It is encouraging that significant portion of these underpayments (as high as 7 to 10 percent) can easily be made good with a refined and robust orthopedic-specific medical billing.
A heartwarming note that speaks right from the heart of a doctor. Indeed, in this age of technology, computers cannot express emotions beyond the script and codes. The son may have lost a parent, but the loss was not in vain.
Physicians’ choice of health plans and contracts seem to be getting fewer and fewer with each passing moment as U.S. health insurance sector, particularly the private sector, witnesses unprecedented payer consolidation, acquisitions, and mergers amongst private health insurance carriers. Besides contradicting the hope that such consolidation, acquisitions, and mergers would bring down the cost premiums for patients, it has virtually helped a few players to wield monopoly over the entire commercial health insurance landscape. The situation has grown so unchecked 70 percent of 385 metropolitan areas in the U.S. do not have competitive conditions, and as much as 40 percent of these areas have a single health insurer controlling the majority share of the commercial health insurance market. As a result, physicians have virtually lost the bargaining leverage that they would have enforced had there been a perfect competitive market for commercial plans.
Stage 2 meaningful use guidelines are finally out, and radiologists may heave a sigh of relief since most of the ambiguity that existed in Stage 1 about their eligibility and the ways to approach the qualification criterion seem to have been made amply clear by CMS and the Office of the National Coordinator (ONC). The American College of Radiology (ACR) needs word praise for its relentless effort in getting most of the necessary changes made to radiology guidelines before the Stage 2 meaningful compliance regime comes into force. While it is not before 2014 that radiologists should complying with newly laid out guidelines, it may still require some crucial adjustments in processes and technology to be fully ready for compliance and qualification under State 2 of meaningful use criterion.
It is an irony that Medicare and Medicaid, which reimburse more than the half of the nation’s total health insurance, have come in for heavy flak by physicians, who claim to have lost considerable revenues that they could otherwise have rightfully earned had they avoided seeing Medicare and Medicaid beneficiaries and favored patients with private health insurance policies. The problem seems to originate from the sustainable growth rate (SGR) formula that has been proved unscientific against exponential growth in public health care beneficiaries and medical cost associated.
Much like medical billing challenges faced by other practitioners, radiologists too will have challenges unique to their own profession. The general perception of billing being more complex than ever before and progressive fall in reimbursements seems to hold good to Radiology Billing as well. As a result, radiologists may see their revenues dropping considerably, which in turn could have disastrous impact on clinical and operational efficiency. With possible threat to sustain diagnostic and radiologic quality amidst a host of clinical and Radiology medical billing challenges, radiologists will have to identify and address the key factors that may carry potentially greatest threats to their revenues, profitability, and more importantly the patient care.