Surprise! “No Surprises Act” Enforcement Delayed

It should come as no surprise that the federal government has decided to delay enforcement of the No Surprises Act.  So although the Act will still take effect on January 1, 2022, the government will not enforce certain provisions of the law until applicable rules are in place.  This will hopefully allow the providers, and the government, time to figure out the best way to comply with the law.

The most difficult provision of the No Surprises Act will likely be the “good faith estimate” requirement.  Under the law, when an individual provider or facility schedules a patient for services, they will be required to gather information about the patient’s payor status.  If the patient has insurance, the provider/facility must send a good faith estimate of the expected charges, billing and diagnostic codes to the insurer.  If the patient is uninsured, that information must be given to the patient.Continue reading

Five Reimbursement Denial Reduction Tips

EOB

EOBBy: Zach Simpson

  1. Review EOBs and determine where denials are originating and their root cause

While reviewing EOBs practices need to determine if a trend can be established that identifies the root cause for why claims are being denied. Trends can be established by asking if most denials are originating in your patient access and registration departments, or are denials occurring because of insufficient documentation, or due to billing or coding errors?

Continue reading

Access to Care via Telehealth Increases Again in Second Round of Changes Due to COVID-19

By: Susan St. John

Access to telehealth for Medicare beneficiaries was further increased by the Trump Administration April 30, 2020. These new changes allows all health care professionals eligible to bill Medicare for services to provide services via telehealth communications and to bill the Medicare program for such services. Additionally, certain services may now be provided using audio technology only.

For a list of services eligible for reimbursement by the Medicare Program, including services requiring audio technology only, download here. There are approximately 180 different codes reimbursable by Medicare if provided via telehealth communications.

Webinar | Emergency Telemedicine Education: From Setup to Billing and COVID-19

emergency telehealth webinarJust the other day CMS issued new rules and temporary waivers to help combat the COVID pandemic. We are getting flooded with questions about telemedicine in particular and wanted to highlight some of the points of the March 31st update that relate to telehealth.

  • Hospitals may use and bill for telehealth services so that patients can be screened without presenting at a hospital. The telehealth screening will allow hospitals to determine the most appropriate site for care, thereby minimizing the patient’s risk of exposure to COVID-19.
  • Health care providers using telehealth will be able to bill for telehealth services at the same rate as in-person services of the same kind and level. Allowable telehealth services have also been expanded during the health care crisis.
  • Importantly, a patient’s home may now serve as the originating site for Medicare telehealth services. CMS is also allowing for required supervision of lower level clinicians to be accomplished through virtual technology if appropriate for a patient’s particular situation.
  • Further, providers, including practitioners, may be able to temporarily enroll in Medicare to be able to assist with the current health care crisis.

Even though CMS has created some flexibility during this incredibly uncertain time…something about telemedicine laws remaining tricky and not being a one size fits all suit. Attorney Susan St. John will give you all of the details on how telemedicine set up, billing questions and more! Join us for this free webinar.

April 14 @ 12:00 pm – 1:00 pm

Free

Modifier 25 Requirements for Avoiding Potential Billing Fraud

modifier 25

modifier 25By: Dave Davidson

On February 4, 2020, the Department of Justice announced a $1.5 million settlement with Southeastern Retina Associates, a 17 physician practice, with offices in Tennessee, Georgia and Virginia.  The sole basis of the claim was the alleged misuse of the Modifier 25 billing code and charging for exams at higher levels than warranted.  The claim was initiated by a whistleblower, who will receive $270,000 from the settlement.

Use and potential abuse of Modifier 25 is obviously not unique to retina surgeons.  In fact, the modifier can be very beneficial to providers, since it allows for payment for those patient visits when the care provided exceeds the scope of the scheduled appointment.  However, given the potential for abuse and the many watchful eyes of the government (the Southeastern Retina case was investigated by the U.S. Attorney’s Office, the HHS Office of Inspector General, the U.S. Office of Personnel Management, the FBI, and the Tennessee Attorney General’s Office) and wannabe whistleblowers, a periodic review of a provider’s billing practices is always a good idea.Continue reading

CMS Releases New mHealth Codes for 2019

mHealth codes 2019 CMSBy: Amanda Bhikhari

Improving patient outcomes while maintaining physician decision making and practice efficiency is key to success in the growing health care arena. Innovation is the ability to see change as an opportunity to create new value, instead of a threat to what we find comfortable. It is clear that the Center for Medicare and Medicaid Services (CMS) is embracing the importance of innovation in the way we deliver health care.

In November 2018, the 2019 Physician Fee Schedule and Quality Payment Program was released by CMS with changes effective January 1, 2019.  This is the time for providers to definitely keep their eyes open to utilizing mHealth, and telehealth services. mHealth is also known as mobile health, and is a general term for the use of mobile phones and other wireless technology in medical care to educate consumers about preventive healthcare services as well as for disease surveillance, chronic disease management, treatment support, epidemic outbreak tracking. The release of the program is a sign that the agency is in favor of expanding the implementation of technology in providing medical care.  The updated mHealth codes are:Continue reading

Time out! Keeping Healthcare Lead Generation in Check

healthcare lead generation

healthcare lead generationBy: Michael Silverman

There are perfectly compliant ways to engage with healthcare marketers, and then there’s this; here are some of the latest real-life examples:

“DME BRACE CAMPAIGN – $40 to $150 PER LEAD PER BRACE”

“DME DIABETIC LEADS $40 PER LEAD, INSURANCE AND DOC INFO INCLUDED”

“PAIN CREAM/LIDOCANE LEADS FOR SALE, RX INCLUDED”

These marketers are seemingly holding auctions for the sale of federally protected patient health information out to the highest bidder! Couldn’t make this stuff up – if you’re in this industry, a quick gander at your (business) social media platforms will quickly confirm it.Continue reading

CMS Announces New TPE Audit Program

Medicare Audit

By: Sharon Parsley

The Centers for Medicare & Medicaid Services (CMS) relies on its Medicare Administrative Contractors (MACs) to serve as guardians of the Medicare trust fund through the MACs taking steps to prevent improper payments.  Despite that reliance, in its most recent report to the US Senate Finance Committee, the Government Accountability Organization (GAO) reports that improper payments totaling $41.1 billion (no, that is NOT a typo, that is a “b”) occurred during 2016 in the Medicare fee-for-service program [1].  That figure represents an overall 11% percent improper payment rate.

How many of us would feel good about being “wrong” in our core job function 11% of the time?  Not very many of us, I suspect.

The GAO report goes on to quote the MACs as generally having ongoing concerns about the following types of claims as those which pose the greatest financial risk to the Medicare trust fund.

Part A Part B DME Home Health
Short inpatient acute care stays and claims for both skilled nursing and inpatient rehabilitation Evaluation and management (including office visits, hospital visits, emergency room visits, and home visits for assisted living and nursing homes) and ambulance services Glucose monitors, urological supplies, continuous positive airway pressure (CPAP) devices, oxygen, wheelchair options and accessories, lower limb prosthetics, and immunosuppressive drugs Home health therapy services and home health or hospice stays that were longer than average

 

So, what does CMS plan to do to hold its MACs more accountable and to further the objective of reducing improper payments?  On August 14th CMS announced an expansion of an ongoing pilot program “Targeted Probe and Educate” Medical Reviews (TPE).

7 Things to Know

The basics of what the provider and supplier communities need to know about the TPE program follows.

  1. The silver lining here is that providers and suppliers with minimal aggregated billing pattern deviations from their peer group coupled with good audit track records may now experience fewer MAC medical review audit requests.
  2. TPE will be concentrated on providers and suppliers with “the highest claim error rates or billing practices that vary significantly from their peers”[1].
  3. In the first round of reviews, MACs will review a 20-40 record probe sample of claims for each lucky provider or supplier selected to participate in TPE.
  4. Providers and suppliers who perform well during the first TPE audit, or who demonstrate significant improvement during the second or third audit may be removed from the TPE audit cycle for a period of up to 12 months.
  5. Each provider and supplier with moderate and high error rates during round one TPE audits will receive provider-specific education, be given approximately 45 days to improve its rate of compliance, and will advance to a bonus round two TPE audit.
  6. Providers and suppliers who fail to improve during the round two TPE audit will again receive provider-specific education, be given another 45 days to improve processes and controls to improve rates of compliance, and will advance to the third round of TPE audits.
  7. Providers and suppliers who perform poorly during the final TPE audit round could be placed on 100% prepayment review, be subject to the dreaded “extrapolation”, and/or be referred to the appropriate Recovery Auditor, Zone Program Integrity Contractor or a Unified Program Integrity Contractor. It goes without saying that none of these are desirable outcomes.

7 Steps to Readiness  

  1. Many providers and suppliers are outliers relative to some component of their billing pattern. Use all the resources at your disposal to “know your numbers” and where your areas of exposure or risk most likely exist.
  2. Closely review results and findings from any recent internal audits or reviews conducted pursuant to your compliance program.
  3. If you have experienced recent external medical review audits, evaluate those results. If there were denied claims, identify the issue or issues leading to the denials.  Then, identify the root causes of errors.  Finally, and most importantly, resolve the problems which lead to denied claims.
  4. If you provide health care services in any of the areas mentioned above which are deemed highest risk by the MACs, examine on your billing patterns in those service lines.
  5. Pay attention to what your MAC says about TPE and areas of emphasis for audit. If you provide those health care services, examine your billing in those areas.
  6. Drill down into any area where your billing pattern materially deviates from your peer group and make sure you understand the basis for the deviation.
  7. If there is no obvious business rationale or justification for a considerable deviation from the “norm” do a deeper dive of your charge capture and billing practices to determine whether any process or practice needs further evaluation and/or adjustment.

These suggestions should position you for a successful outcome if / when you are selected to participate in the TPE audit program.

Out of Network VOB Process Hits a Speedbump

VOBBy: Urgent Medical Billing, Guest Contributor

The verification process is an important step in the billing cycle. When done correctly the patient’s “VOB” will allow a healthcare provider to quickly determine if they can accept the patient for treatment or not. A good verification will tell a provider the general information about a patient’s insurance policy such as the deductible, the co-insurance and the out of pocket maximum. A very good verification will also include accreditation requirements, information on who would receive the payment for services, correct claims addresses for professional and facility charges and more. The quicker a verification is done, the sooner a patient can be brought into treatment. Speed and accuracy is the name of the game when it comes to insurance verification and United Healthcare, until very recently, was one of the quickest policies for an Insurance Verification Specialist to work with. Continue reading