Insurance & Reimbursement

Dual Medicare-Medicaid Billing Problems

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):

Anthems original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers.  The policy was to go into effect March 1, 2018, however, due to strong opposition from the American Medical Association and other groups Anthem decided it was not in the best interest between payers and providers. 

Workers Compensation

Workers’ Compensation is for work related illness or injuries on the job. The employer pays for insurance which covers medical costs incurred, and replaces lost wages. Fees are based on a specific fee schedule that varies by state.

Establish Patient Financial Responsibility (Resource 149)

Financial responsibility (insurance, cash, etc) should be established as soon as possible, preferably before the patient comes in for the first visit. Both provider and patient need to understand who is responsible for payment of services. The patient needs to understand what they are responsible for versus what the insurance plan or company will or will not pay. Consider the following:

Medical expenses are one of the largest expenses in many United States households. Medical bills and insurance remittance are also possibly the most difficult of all bills for patients to interpret and understand. 

Fee Schedules
Do you know what the fee schedules are for each of your top insurance companies?  Do your providers know how much they are getting paid for the services they provide and manage their practice to maximize reimbursement?

Learn how to maximize reimbursement by knowing, understanding and using insurance fee schedules properly.

Collecting and maintaining insurance fee schedules each year can help your practice in many ways.  But, you must obtain the fee schedules first.

ATTENTION In-Patient Hospitals

CMS has announced a settlement request to Inpatient hospitals for claims in appeal status! Due to the unprecedented growth in claim appeals the demand continues to exceed Medicare’s available resources. CMS has made an offer in hopes of quickly reducing inpatient status claims currently pending in the appeals process. CMS is cleaning house and has made this administrative offer to Inpatient hospitals only.

Skilled Nursing Facilities (SNFs) must issue a liability notice to Original (fee for service) Medicare beneficiaries before the SNF provides:

  • an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or custodial care.
  • For Part A items and services: SNFs may use either the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or one of the five SNF denial letters as the liability notice.

The following are examples of when a drug is not directly related or integral to a procedure, and does not facilitate the performance of or recovery from a procedure. Therefore the drug is not considered a packaged supply. In many of these cases the drug itself is the treatment instead of being integral or directly related to the procedure, or facilitating the performance of or recovery from a particular procedure.

Most of us have seen the news reports on problems of veterans seeking healthcare benefits through the Department of Veterans Affairs. Several factors such as the misuse of funds and controversial bonus systems seem to have combined to create this current newsworthy crisis. Critics argue that the VA's performance bonus system created financial incentives for managers to hide the true number of patient's on their waiting lists. Whistleblower claims are backing up this argument. The fact that many veterans have died while on waiting lists has fueled this crisis.

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