Medical Billers and Coders

  As physicians, doctors, healthcare units, ASCs, and  medical billing and coding companies  observe this year’s passage of the newly laid  MACRA/MIPS  reporting rule, there are a lot of dilemmas about its positives and avoidance for the year 2018. However, it will be important to notice whether the final rule continues to trend toward value-based care. Also, given the intricacy and sweeping nature of QPP, it is yet to be seen whether or not positives and avoidances will alleviate administrative burden. Understanding the MACRA/MIPS Proposed Rule Experts, including those working in the government, who are keenly observing the scenario, have some important takeaways from the proposed rule: Around 34%-36% of physicians will be eligible for MIPS after all exclusions, although they make up 55%-58% of Medicare Part B charges. MACRA/QPP is an enormous piece of legislation. At its business end, it will eliminate the sustainable growth rate formula and replace it ...

  Managing legacy accounts receivable can be a challenge for hospitals. These outstanding balances can be difficult to collect and may have been on the books for years. They can negatively impact a hospital’s cash flow, financial performance, and overall stability. However, with effective management strategies and best practices, hospitals can tackle the puzzle of legacy accounts receivable and boost their revenue. The Hidden Costs of Unpaid Medical Bills Image Source The financial burden of unpaid medical bills is a significant issue for hospitals. When patients do not pay their outstanding balances, hospitals are left with uncompensated care costs that can impact their bottom line. Uncompensated care costs include both bad debt, which is when a hospital cannot collect payment from a patient or insurance company, and charity care, which is when a hospital provides care for free or at a reduced cost to patients who are unable to pay. In addition to the direct financial impact...

  The behavioral health industry has historically lagged behind physical healthcare in adopting value-based and outcomes-based care models. Value-based care is also known as accountable care. A value-based care system is focused on getting value from quality services. Value-based healthcare is a payment system that rewards healthcare providers in accordance with the quality of care provided to their patients. Payments are based on better health for populations and other things, such as cost reduction, which can lead to a focus on preventative care. The benefit of value-based care is a patient in a value-based healthcare model will have fewer doctor’s visits, medical tests, and medical procedures. Additionally, they pay less for medication as their health gradually improves. BlueCross BlueShield came into the value-based reimbursement arrangement with Value Network. The provider group has 100+ providers in behavioral health care in Western New York. “This is another step we’re t...

  The US healthcare is evolving. To improve pharmacy Revenue the pharmacies need to be equipped with a better billing system. Here are some challenges faced by pharmacies that cause billing errors and affect customer relations, revenues, and reimbursements: Access to the patient’s eligibility at the time of service may be unavailable. The staff may not be updated with information about various drugs, allergies, maximum dosage, billing system, rules, codes, and insurance clauses. Claim denials due to unspecified codes put pharmacies at risk. An increase in turn-around time, duplication of work, workforce shortage, and inefficient time and energy utilization of staff members in case of critical cases, could lead to billing errors. Medical billing cannot process vaccine claims covered by pharmacy or medical benefits. The  pharmacy billing  system is not scalable or flexible. Incorrect CDM could result in underpayment, claims denials, and fines. Incorrect paym...

  Ambulatory billing refers to the process of generating and submitting accurate claims for services rendered at ambulatory surgery centers. In the rapidly evolving landscape of healthcare, ambulatory surgery centers (ASCs) have gained significant prominence as a cost-effective and efficient alternative to traditional hospital-based care. As the demand for ASCs continues to grow, it becomes crucial for ambulatory owners to optimize their revenue cycle management processes, particularly ambulatory surgical center billing. This blog aims to shed light on the importance of  Ambulatory Surgical Center Billing  and the benefits of outsourcing these services to a reliable medical billing company like  Medical Billers and Coders (MBC) . Understanding Ambulatory Billing  It involves coding procedures, documenting medical necessity, verifying insurance coverage, and ensuring compliance with regulatory guidelines. A well-executed ambulatory billing process is essenti...

  Basics of Telehealth Physical Therapy Medicare covers three types of telehealth physical therapy services i.e., telehealth services, e-visits, and virtual check-ins. But physical therapist still needs to follow a few basic practices for getting paid for telehealth physical therapy, let’s discuss them. During the c, the federal government has broadened access to telehealth services including physical therapy. With revised billing guidelines, all beneficiaries can now connect with their healthcare providers online, and providers will get the same reimbursement for these services as they would for in-person sessions. Verification of Identity Given that in the telehealth clinical setting, the beneficiary and therapist are not in the same location and may not have established a prior in-person relationship, it is critical, at least initially, that the identities of the physical therapy providers and beneficiaries be verified. Photo identification is recommended for both the benef...

  EDI in medical billing helps doctor’s offices, hospitals, labs, pharmacies, and other healthcare facilities to communicate with each other. In today’s world of electronic claim submission, electronic data interchange (EDI) has become an essential component of medical billing processes. EDI enables healthcare providers and insurance companies to exchange crucial billing information efficiently and securely. This article will explore the details of EDI in medical billing, exploring its significance, working mechanism, and benefits in medical billing. What Does EDI Stand for in Medical Billing? EDI stands for electronic data interchange. In the context of medical billing, EDI refers to the electronic exchange of standardized healthcare transactions between healthcare providers and insurance companies. It involves the transmission of data in a structured format, allowing for seamless communication and streamlining of billing processes. Electronic Billing and EDI Transactions El...

  Physician Self-Referral Law (Stark Law) Basics The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive Designated Health Services (DHS) payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship unless an exception applies. Financial relationships include both ownership/investment interests and compensation arrangements. The term Stark Law refers to former U.S. Representative Pete Stark of California, who originally introduced the  physician  ethics bill in the late 1980s that would later evolve into this law. At that time, healthcare services were provided mostly on a fee-for-service basis, meaning that healthcare providers (HCPs) were paid a predetermined amount for each type of service performed, rather than the current value-based system that focuses more on patient outcomes.  The fee-for-service healthcare delivery ...

  The Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & Educate (TPE) audit, effective September 1, 2021. Based on data analysis of claims payment, CMS will identify areas with the greatest risk of inappropriate program payment. CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. Let’s focus on the basics of Medicare TPE audits. A TPE audit is a close examination of the billing practices that a healthcare provider uses for its Medicare claims. The provider’s Medicare Administrative Contractor (MAC) conducts the auditing process. If unusual billing practices, mistakes, or discrepancies are found between the Medicare claims and the healthcare services that were provided to the patient, the MAC will help the provider fix the problems and show them how to avoid making them in the future. Even though the MAC conducts the audit, the  Centers for Me...

  HIPAA was officially enacted in the year 1996 by the United States Congress.  HIPAA  has two titles–Title I of the rule is to protect individuals and families when they lose their jobs or change their jobs. Title II also known as the administrative simplification provision requires the establishment of electronic healthcare transactions to protect the identity of providers, health insurance plans, and employers. All Covered Entities and Business Associates must follow all HIPAA rules and regulations. Title I has been a debated topic with health coverage of many individuals going under constant change looking at the job security of American individuals. I am covering individuals under health care policy after significant breaks. Title II is known as the background regulation of the healthcare industry as the industry moves toward the technologically vibrant sector.  With Information becoming the new currency, the law was made to protect the patient’s healthcare i...

  Vagus Nerve Stimulation (VNS) is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve. Electrical signals are sent from the battery-powered generator to the vagus nerve via the lead. These signals are in turn sent to the brain. VNS provides indirect modulation of brain activity through the stimulation of the vagus nerve. The vagus nerve, the tenth cranial nerve, has parasympathetic outflow that regulates the autonomic (involuntary) functions of heart rate and gastric acid secretion and also includes the primary functions of sensation from the pharynx, muscles of the vocal cords, and swallowing. It is a nerve that carries both sensory and motor information to/from the brain.  Medicare coverage  for many tests, items, and services depends on where you live.  Nationally Covered Indications  VNS treatment is reasonable and n...

  Account Receivable (AR)  is one step that divides the reimbursement and claims; the older the claim gets the harder it becomes for claims to get reimbursed. For practice when AR slips below a certain level you either have a pretty large backlog to be sorted out, or you can see that it becomes impossible to tackle the day’s run-out without any futile results.   The major challenge is that in recent years the financial responsibility and medical care for patients have compounded but on the other hand, we see that the widespread reach of more and more products through new healthcare insurance exchanges has prompted higher deductibles or coinsurance for physicians. As physicians cope with unfamiliar issues with different insurance companies, the AR suffers dearly. Here are three factors you can look into to solve your AR pile-up mess. 3 Unknown Myths about AR Pile-Up Step up the insurance verification process The starting point of addressing AR issues is the f...

  PAR and non-PAR Providers with Medicare The Center for Medicare & Medicaid Services (CMS) is a federal agency within the Department of Health and Human Services that manages and oversees the Medicare program for beneficiaries. Physicians are required to comply with numerous laws and regulations related to various aspects of their practice within the Medicare program. Each year physicians have the opportunity to review and modify their contractual relationship within the Medicare program. Participating providers are referred to as ‘PAR’ while non-participating providers are referred to as ‘Non-PAR’. Providers need to understand their options within the program to ensure proper reimbursement. The primary difference between being a PAR and a non-PAR Provider lies in how fees will be collected. The three Medicare contractual options available for physicians are as follows: Participating (PAR) providers can sign a participating agreement and accept Medicare’s allowable charges...