Insurance & Reimbursement

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.

EHR Incentive Programs: Exclusions and Hardship Exceptions

CMS offers exclusions and hardship exceptions for eligible professionals who face challenges in meeting meaningful use objectives that require that they and their patients have broadband access and Internet connectivity.

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.

Medicare has set Annual Therapy Caps at $1920 and they start over Jan 1 of each year.  Medicare  combined the therapy limits SLP (Speech-Language Pathology) and PT (Physical Therapy) for a combined total of $1920.00 in 2014. There is also a Therapy Cap limit for OT (Occupational Therapy) Services of $1920.  These both have a threshold of $3700. (Be sure to contact your local carrier to verify limits).

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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