Overcoming Recent Billing Challenges with Efficient Medical Billing Services

Overhaul of codes, forms, rates and standards: the current year is going to be very eventful for care providers from a medical billing and coding standpoint. But whether you will emerge through these challenges 11 months later with your revenues stronger or weaker - depends on how well you can prepare your practice to meet the challenges.

If you closely look at the four challenges cited at the beginning, you will understand the wide-ranging impact they will have on cross-sections of your practice. This article will closely look at the specific issues, but it will first explore Healthcare exchanges (HIXs).

HIXs are meant to implement the principle of Affordable Care Act (ACA) which seeks to expand the base of insured Americans by making insurance policies cost effective. In practice, HIXs will allow a large number of insurers to sell policies at affordable rates to American citizens increasing the number of insured Americans to 40 millions.

This is highly commendable, but how HIXs will set the lower rates of insurance policies to facilitate this huge leap in number of insured Americans is not known; but that this will lead to plummeting reimbursement rates for physicians is easy to foresee. And this follows a two percent slash in Medicare rates, affected in April 2013.

But the good side of this rate decrease is that it’s going to a huge base of Americans (about 35 to 40 millions) to the current patient increasing the number of patients per care provider substantially.

Additionally, transition to ICD 10 from the ICD 9 platform has kept care providers concerned, especially with the effective date of 1st Oct. 2014 nearing. The wide-spread concern is justified for various reasons. ICD has 13000 diagnostic codes while ICD 10 includes 70000, which leaps to 155000 if you include the procedural codes. Not only that. Medicare & Medicaid Services introduced a new form which practices have to use to submit their claims.

Moreover, ICD 10 will also require practices to move to a new HIPPA platform, which means additional operational adaption and cost for them. No wonder ICD 10 is being seen as the biggest ICD code overhaul in years.

MBC has been helping many care providers, both in small and big cities of the US, to overcome their billing and coding challenges. We have guided many practices in setting up EHR so that they can handle larger number of patients and leverage the current HIX-caused patient influx. We have also helped practices with ICD 10 transition.

Our Revenue Management Consulting services can help you to fix and optimize your revenue management cycle. To help you do this, we assess it and identify it through training, installation of proper software applications etc.

Medicalbillersandcoders.com the largest consortium of billers and coders in the US, has also been helping many practices to overcome challenges of slashed rates and ICD 10 with its outsourcing medical billing services handling the entire range of activities involved in billing and coding, starting from preparation of claims through submission to post-submission follow-ups. Our service modules are flexible and you can pick and choose only those pieces of our services that meet your coding needs so that you can avoid paying additional cost.

Challenges Push Family Practitioners to Partner with Billing Specialists to Improve Revenue

Despite the delay in implementation of 26.5 percent cut in Medicare family practitioners payment, AAFP continues to call on Congress for a repeal of the sustainable growth rate (SGR) formula. This is understandable because the deferment means a temporal relief for family practitioners and if SGR is around, given that it assesses growth solely from a financial standpoint, payment cuts introduced without taking medical and human factors into account will continue to recur.

Though, this cut which is framing the political discourse around primary healthcare in the US is a recent phenomenon (the cut was scheduled for implementation on 1st January, 2013), if we go about a year back and take the case of Dr. Hammond, we will see financial problems have been ailing family physicians for some time now.

Dr. Hammond is an independent family physician with a clinic in Denver who ramped up his in-house IT operations and staff to make his practice and services more holistic, such that with his increased staff strength and upgraded IT his practice is able to cover the entire need of a modern-day healthcare operations starting from keeping in touch with patients to track their health and progress to maintaining electronic data. It’s the most ideal practice to have, isn’t it?

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Though, Dr. Hammond and many family practitioners across the US have upgraded their family physician practices to meet the modern needs of healthcare (like outreach and coordination), the fact remains that these enhancements are not reimbursed under traditional insurance contracts making profitability difficult. This together with new payment reforms which encourage healthcare providers to come together is making independent family practitioners a dying breed in the US. Whether this is good or bad for US healthcare is debatable, but a close look at Dr. Hammond’s operations would reveal that it includes lot of things that are not part of core physician practice (like IT data maintenance) and could be kept out to keep the operations thin, nimble and cost-effective.

And as family practitioners wake up to the prospect of frequent cuts in Medicare family physician payments, there problems seem to be getting enough and counting. However, to upgrade their operations, thwart the effects of Medicare cuts and also to gear up for the innovative payment model, many family practices have been joining Accountable Care Organizations (ACOs) or setting them up.

But transitioning to ACOs from their traditional mode of practice may not be easy as it involves negotiating pay schedules, negotiating payer contracts etc. Also, it requires monitoring and analyzing information, like eligibility for Medicare, medical outcomes, Medicaid and private insurance, and clinical compliance and reimbursement requirements to name a few. Family practitioners in addition to the Medicare cut challenges will have to ensure ICD-10, HIPAA 5010 compliant billing and coding along with EHR and PQRS.

Medicalbillerandcoders.com, the largest consortium of billers and coders across US, has also been helping various healthcare providers with billing and coding services for over a decade now. MBC’s Revenue Management Consulting services can help family practitioners by assessing their in-house revenue management cycle and ensure sound coordination between various components of healthcare, facilitating smooth flow of medical data for ACO operations and otherwise.

We also identify gaps in your process blocking areas of revenue leakage and identifying areas of staff training.  Additionally, we can help train your staff to  replace applications where required and handle new billing and coding challenges like EHR, PQRS, and ICD-10, and HIPAA 5010 compliance so that they can make error-free insurance claims.

Overcoming Cardiology Billing Concerns in 2013 with Complete Revenue Cycle Management

As a specialized healthcare field, Cardiology has cherished generous government support for testing services and unhindered reimbursements. However, with new developments in Patient Protection and Affordable Care Act (PPACA) and lower reimbursements given recent healthcare reforms, Cardiology billing is expected to face some serious issues in 2013. In addition, ICD -10 and HIPAA regulations are bound to complicate the financial scenario for Cardiologists. Some of the major concerns in Cardiology Billing are expected to be –

• New Regulations & healthcare reforms – PPACA, ACA, HIPAA and ICD – 10 are some of the most popular regulations and reforms that have shaken the healthcare industry. Cardiologists are facing disconcerting billing issues, patient data documentation issues and coverage related dilemmas

• Reduced Reimbursements – Due to ever-increasing complexity of claim procedures for insurance providers and reduction in reimbursements from Medicare and Medicaid by up-to 25%, financial performance of every Cardiology Practice is bound to take a hit

• Consolidation and ACA – With increasing consolidation of large hospitals and independent practitioners, surgeons and physicians are losing their autonomy. Many organizations and practices are participating in Accountable Care projects to reduce costs but are in turn exposing themselves to heightened risks as well

• Increased no. of patients – With 30 million more patients expected to be covered by the end of the year 2013 as per new government healthcare reforms, burden on care providers is expected to increase multifold

• Stress on Quality of care – Increasing shift towards quality of care is adding to the service expectations from Cardiologists. Coverage is denied and audit issues arise in case of re-admittance of patients that had cardiac procedures administered on them within a 30 day time period

Despite prospects of difficult times ahead, Cardiology Billing concerns can be effectively addressed with efficient Revenue Cycle Management (RCM). RCM is gaining popularity with healthcare service providers due to the unparalleled time and freedom it offers practitioners to focus on patients. Judiciously aligned RCM can enhance productivity of billing process and reduce financial concerns dramatically-

• Accurate RCM reduces the claim denial rate by arranging pre-authorizations and checking patient coverage with insurer at the time of registration itself
• RCM monitors claim filing and coding process for immaculate documentation and patient record maintenance, that supports efficient billing
• Effective RCM improves revenue capturing and collection of outstanding bills by applying effective denial management, capturing proper documents, handling claim entry and secondary billing
• RCM also analyzes and realigns the payer mix, ensuring improved payouts per revenue cycle by cutting down the risk of practice

Expecting a Cardiologist to handle all this while delivering quality care service is like hoping for a daily miracle. Medicalbillersandcoders.com is therefore nothing short of a miracle partner that can solve all your Cardiology Billing concerns. We improve access management, handle regular claim denials with impeccable turn-around time and expedite cash collections. With a team of experts dedicated to handle all aspects of Revenue Cycle Management, medicalbillersandcoders.com transforms your Cardiology Billing concerns into guaranteed financial success.

How will the Affordable Care Act Impact Cardiology Practitioners and Their RCM?

Healthcare industry has been undergoing steady reforms over the past couple of years and the changes are expected to continue. The objective of this ongoing transformation is to achieve improved healthcare services with increased focus on quality care. In such a scenario, Affordable Care Act is being viewed as a promising way of improving healthcare and strengthening financial conditions of the industry. However in addition to expansion of coverage, increased accountability of insurance companies, lowering of healthcare costs and enhancement of quality care for Medicare patients; ACA is expected to increase revenue risk for physicians as well. As a shift from fee-for-service to revenue and cost sharing model of ACOs (Accountable Care Organizations), Cardiology practitioners will face a lot of challenges in realigning their revenue cycles.

Some of the major RCM parameters that ACA will affect practitioners are –

• Due to bundling efforts, cardiovascular coding will undergo additional changes
• Medicare fee schedules will change for physicians in addition to the continued threat of reimbursement cuts by 30% due to SGR
• Penalties for non participation in federal incentive programs like EHR, quality reporting system and e-prescribing
• Government and commercial insurers will pay for value based services (pay for performance reimbursement model) instead of continuing with the volume based or fee for service model
• Increased number of Medicare patients to be covered by Cardiology practitioner participating in ACO project, meaning more financial risk and heightened burden on RCM

With rising focus on quality care and expected collaboration between hospitals and independent medical practitioners under ACA, to cut down costs and enhance care coverage, Cardiologists will have to adapt their practices and RCM as per the imminent changes.

RCM or Revenue Cycle Management is the strength of any medical practice aiming to stay financially viable. RCM cannot afford to stagnate in its processes as the healthcare environment is changing on a continual basis. With industry changes, RCM of a Cardiology Practice must transform to better suit the needs of the practice. Given a high likelihood of ACO participation by most Cardiology Practices, some well planned changes in RCM can prepare a practice to absorb heightened risk and derive better revenue from ACO –

• Compliance to changing regulations and participation in federal programs designed to incentivize practice performance can save your practice a lot of future costs and penalties. Thus RCM of your Cardiology practice must comply with new regulations and keep your practice up to date
• Change in fee schedules and expected reduced reimbursements by Medicare would mean diminished revenues. Thus focus of your RCM must be to diversify the payers mix to absorb this inevitable decline in revenue
• Coding and billing changes due to bundling must be tracked and updated in your system to avoid any claim denial or audit complications
• RCM must strive to adopt value based reimbursement model for your practice and gradually shift away from fee for service payment model

As RCM and billing experts, delivering optimum medical billing and coding services across all 50 US States, medicalbillersandcoders.com can help add value to your revenue model and save you tremendous costs and expenses. Your Cardiology Practice can benefit from our billing and coding experts help and our accurate revenue cycle management can transform a high risk ACO project into a high return venture for you.

How Can Outsourcing Help Better Position Your Practice for Pay-for-Performance?

Pay-for-performance programs are a great way of rewarding health care providers but do you have the time and resources to make your medical practice eligible for such rewards?
There is no doubt that these programs provide encouragement to doctors and better services to patients but several challenges are also related to pay-for-performance-

• In order to become eligible for these programs, you will be required to reduce variation in your clinical practice
  
• You will have to reduce errors by promoting effective medical safety practice and offering best care to chronically ill patients
  
• As per the present system for Pay-for-performance, factor like reduction in glycohemoglobin for diabetic patients is also a scale on which your performance will be measured
  
• Whether or not your practice will become eligible for P4P also depends on your patient’s hospital stay and emergency room visits. Care co-ordination of patients suffering from chronic diseases between home, hospital and office is also a criteria for rewards
  
• If you happen to use health information technology for improving health of your chronically ill Medicare patient, you will be rewarded under these programs. You will also have to devote enough time and energy to ensure that patients coming at your clinic are well-informed and empowered
  
• In case you don’t participate in P4P programs, you will not only lose patients but also your market share

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How can pay-for-performance benefit you?
If your practice gets to win an incentive award under pay-for-performance program, it will give you an edge over other health care providers. This will result in increased flow of patients at your clinic which will eventually add to your income.

How to make it happen?

At a time when the US healthcare system is facing strain on finance and healthcare delivery due to inflation of medical cost, it has become imperative to offer high quality medical services at an attractive cost. This can happen only when you make your practice eligible for these P4P program by concentrating more on patient care rather than billing and account receivables.

Is AR management and medical billing restricting you?

You may have the capability to offer enhanced medical care to the patients and tackle P4P challenges but tasks like medical billing and account receivable management can eat up all your precious time that can be otherwise devoted in best medical care facilities.

Taking into consideration the complexities of healthcare industry in the US, many physicians are outsourcing these services and buying precious time to prepare their practices for pay-for-performance programs. So, if you also want to improve your services and get the competitive edge, why not make use of increased time and look into patient care?

Medicalbillerandcoder.com has been offering outsourced billing and AR management services to physicians across 50 states in the US. The expert team at MBC also provides consultancy to help doctors enhance their in-house practices and improve health care services to their patients.

Physicians Realign Their Strategies to Meet the Challenges of Healthcare Reform

After reforms, the American healthcare industry is seeing a curious change: healthcare providers are adjusting their practice models to suit the needs of Affordable Care Act. A quick look at some of the factors that are provoking these changes will bring about how the changes have not left (or will not leave) any aspect of healthcare operations untouched.

The reforms will completely alter the mode of payment in which healthcare providers are paid by insurance authorities. The mode of payment will go from pay-per-service to per-visit or per service mode. Additionally, the provider will be paid in the form of bundled payments so that there is scope for promoting quality even as costs are driven down.

As far back you can see Medicare’s Physicians’ Quality Reporting System (PQRS) was around as a quality reporting standard which laid down quality parameters for physicians to report on. Albeit, now this reporting is going to become more rigorous: unlike until recently when physicians used to report only on data, now their reports would have to show that they meet each quality metric.

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Bundled payment is perhaps the biggest change driver of the reform. Because bundled payments require coordination among various care disciplines involved in providing care, the reform gives the physician’s role prominence over that of the hospital.

As a result of this, surveys have revealed, 70% of hospitals are expanding the number of physicians on their staff to position themselves such that they can handle any initiatives resulting from the reform law. Additionally, bundled payment is also making care providers to either join or set up their own Accountable Care Organizations (ACOs).

Whether it is the mode of payment, the reporting methods, expansion of physician employment in hospitals, the singular area that the changes seem to gravitate towards is insurance reimbursement – how claims are made, medical data gathered to make them, codes (CDT) used, insurance claims paid, etc. And this is not a surprise as the reforms are focused towards bringing down the cost of care; promoting the number of people insured, and improving quality of care.

So equally unsurprising is the fact that the last few months have seen an increase in the number of care providers approaching professional billers and coders to help them sort out their post-reform concerns. However, you would require billing and coding organizations that can combine traditional knowledge with keen awareness of the current changes and how they affect the billing and coding processes and practices.

Following reforms, MBC has helped several healthcare providers to be equipped to face the challenges of reforms either by strengthening their internal operations or by handling their complete billing and coding responsibilities.

MBC’s Revenue Management Consulting services helps providers by assessing their in-house revenue management cycle and ensuring that there is sound coordination between various components of healthcare facilitating smooth flow of medical data for ACO operations and otherwise. We also identify gaps in your process and address them if necessary.

Medicalbillerandcoders.com, the largest consortium of billers and coders in the US, are constantly updating themselves with current healthcare industry trends. In addition serving all 50 US states across varied specialties for more than a decade, MBC experts have the required expertise and experience in Medical Billing and Coding to help clients handle the upcoming reform challenges effectively.

Improving your AR by Switching to a Billing Service for Your Medical Practice

One of the most frustrating issues for a physician is delivering quality medical services and not getting paid for it. Your practice can become successful only when the receivables are captured at all times. In absence of follow ups, you will not be able to recover the deserved amount as the recovery process becomes close to impossible once the account receivables reach 120 days.

What causes long-pending account receivables?

If your staff is not efficient in monitoring and keeping the account receivables of your practice active, it can become extremely difficult to retrieve the amount after a certain period of time. Usually, the entire process of finding out reasons behind delays, claim denials, following up with insurance companies, resubmitting the claims is extremely tedious due to which a significant number of physicians in the US lose thousands of dollars in the form of long-pending account receivables.

Some of the challenges you might face with account receivables are:

• Denial of an insurance claim-
  If your patient is considered non-eligible by the insurance company, the claim will be denied and your payment will get delayed. In this case, claim (paper or electronic) will have to be resubmitted and regular following up will have to be done every time the claim is denied. If you file the claims beyond the claim filing limit, your account receivable will become next to impossible
  
  
• Coding errors-
  Revisions are being done to CPT and HCPCS Level II codes annually and with the growing number of patients, and in this scenario your staff happens to make any coding error, AR will get delayed till the matter isn’t resolved
  
  
• Delayed payments-
  Sometimes government aided insurance companies don’t make the payment on time which again delays the payment process for physicians. In this case, too much time goes in constant follow up with the payers
  
  
• Adjudication issues and documentation-
  There can be certain adjudication issues and requirement of additional documents or clarification for patients that needs to be catered in time to ensure that AR doesn’t get delayed

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How can you improve your account receivable?

Account receivables will get converted in revenue only when you are dedicating enough time and resources into follow-ups, error-free claim resubmission, analysis of denials, maintaining past AR records, staying updated with new policies and procedures and so on.

To manage account receivables, you will have to perform:

• Timely follow-ups with patients as well as insurance companies
• Analyse the reasons for claim denials, fill the claims forms again without errors and submit them
• Keep updating the list of long-pending ARs and work towards getting the revenue

The entire AR cycle management demands substantial amount time which can distract physicians from offering quality patient care which very few can afford currently. Medicalbillersandcoder.com has been offering effective AR management services to physicians across 50 US states. We offer in-dept analysis-backed AR management solutions or customize parts of it to your practice needs so that while we help retrieve your revenue you can concentrate on offering medical services.

Aligning your medical billing goals with your Practice’s Goals!

A truly successful medical practice in today’s evolving healthcare industry is one that has its goals aligned with its medical billing goals. To a physician, however, it may seem like yet another time consuming task, but well determined objectives of a medical practice, if successfully translated into billing and coding practices can result in enhanced efficiency and greater profitability.

Many practices outsource their medical billing functions to third party experts, who work on pay-for-performance principle. This in-turn ensures that the billing experts work in sync with the revenue goals of the practice, for they get paid only when you get paid. Another way to go about medical billing is enhancing the in-house function; along with implementing performance based compensation to in-house staff may help do justice to your revenue goals.

Goal alignment has become the need of the hour for maintaining the competitiveness of your practice. The following steps can assist you in effective definition of practice goals and alignment of the same with medical billing goals –

• Identify your primary goals – Medical practice is built around the primary goals of patient care and service, which can resultantly improve revenues. Although profits and revenue are not primary goals, they are essential elements of every practice. Thus, it is crucial to write down goals in clear statements such as – “our goal is to maximize revenue while delivering unmatched healthcare and medical service to each and every patient” or “Assist patients in accessing healthcare service at reasonable costs and without wastage of time.”
  
  
• Communicate these goals to the medical billing staff – Once your goals are defined, make sure to discuss the same with your billing staff. Many physicians deign to indulge in the financial aspect of their practice and thereby lose out on a big chunk of their revenues. Medical billing goals are primarily focused on payment collection, correct coding, claim filing and reimbursements. Each activity takes new meaning if only practice goals are communicated well to the billing experts, whether external or internal.
  
  
• Monitor the gap in understanding and training – Keeping a track of staff activities and billing reports can effectively prove if medical billing goals and practice goals are aligned or if there is some gap in staff or consultant understanding. Regular interactions and consultations will lead to clearer goals and efficient achievement of the same.

• Update goals as per the changing industry scenario – HIPAA and HITECH guidelines, in addition to EHR regulations and RAC procedures have necessitated extreme caution and care to be applied while handling with patient data. Medical billing and coding goals are required to be more data and revenue centric rather than service oriented. However, a balance can always be established between conflicting goals.

Medicalbillersandcoders.com can help you define your practice goals and align them with medical billing goals. We can facilitate you in achievement of your financial and service objectives on a continual basis by understanding your practice objectives and applying them to your billing practices.

Our billing experts have been serving healthcare specialists in varied domains across all 50 US States for more than a decade now. We help physicians concentrate on patient care as we handle their entire revenue cycle process in line with their medical billing goal; along with assisting them in aligning their practice goals with the help of our experts’ in-dept healthcare industry knowledge.

Protecting Your Practice Against RAC Audits With the Help of Efficient Medical Billing Practices

Efficient medical billing practices can make or break your medical practice and if anything can verify this statement, it is an RAC audit. RAC audits of Recovery Audit Contractor audits are nothing short of a nightmare for any healthcare provider.

Medicare and Medicaid are two healthcare carriers that provide coverage and reimburse physicians and hospitals for the services they provide to patients covered under these carriers. However, medical practitioners are known to receive over-ayments due to incorrect claims or erroneous coding at the time of medical billing. In essence, government tries to ensure patients’ best interest and control the rate of fraud, error or wastage by putting RAC audits in place. But the resultant inconvenience caused to a medical practice in the event of an RAC audit is nothing short of disastrous.

Not only is error-free coding and meticulous book keeping of paramount importance, subsequent adjustment of office accounts can play an important role in case an RAC audit actually happens. To protect your practice against RAC audits, you must put efficient medical billing practices in place –

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• Follow correct coding for services –If a medical service is incorrectly coded for the sake of avoiding internal confusion or due to oversight and the incorrectly coded service is reimbursed by Medicare or Medicaid; then your practice can be in for an RAC audit. Transparent and efficient medical billing practices help you monitor coding of services on a regular basis and avoid simple yet latent disasters, hence with a little more attention, you can save your practice a lot of money and hassle.
  
• File claims for correct payment amounts – Scrutinizing the final claim statement filed with healthcare carriers is of paramount importance. If the government settled an incorrect payment amount to your practice, as long as five years ago (as per recent healthcare reforms, the RAC audit period for overpayment has been extended from three years to five years) then your current financials can suffer drastically. Diligent book-keeping is a medical billing practice that can help you avoid this scenario altogether.
  
• Avoid duplicate services – It may not be fraud at all, but mention of duplicate services is rarely ever seen as an honest human error by an auditor. A prudent medical billing practice is installing audit software or enlisting the service of a compliance auditor, to fix your errors before an actual audit.
  
• Don’t claim for non covered services – Services that are not necessary and reasonable under section 1862(a) (1) (A) of the social security act are not meant to be reimbursed by Medicare or Medicaid. Avoiding inclusion of the same in your claim amount can save you from a potential audit.

Medicalbillersandcoders.com an expert in medical billing and coding serving the healthcare industry for more than decade now can help protect your practice from potential RAC audits by offering immaculate medical billing consultancy and services.

RAC auditors conduct audits on providers in response to insider information or complaints, upon diagnosing irregularities in billing and coding practices as per the CERT or other CMS analysis. With comprehensive and efficient medical billing practices in place with the help of our experienced medical billers and coders, our client’s practices are well equipped with all the required defenses in place to protect themselves against an RAC audit.

Are Medical Practices Moving Forward at the Same Pace as Healthcare Reforms?

Healthcare Reforms or Obamacare that had been facing a few political hurdles may have finally broken through all shackles and assumed greater acceleration. While healthcare reforms or Obamacare are largely perceived to pro-patient, physicians or medical practices have no option but to move with the requisite adaption. Amongst a host of reforms, the recommendation of the Affordable Care Act, which seeks to make medical care affordable to every US citizen, may possible be the most demanding adaption ever to have been undertaken by medical practices. This ominous burden plus the pulls of other reforms may have actually impeded their progress, which is currently way short of the expected. In fact, the industry sources believe that medical practices across the US are still struggling with implementation stage of adaptation to healthcare reforms mandates.

What makes these healthcare reforms so daunting is that:

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• Medical practices would find themselves treating more number of Medicare patients than ever before. The extension of Medicare to pre-existing cases as well as dependents under the age of 26 could prove to be exhausting of physicians, who are likely to be disproportionate or short against the patient population. According to a reliable estimate the extension of Obamacare could leave the primary care sector short by 90,000 physicians by 2020!
  
  
• The likelihood of reimbursements being progressively reduced for specialties – contrary to the general feeling of reimbursements improving with patient volume, the proposed Medicare cuts would reduce physicians’ reimbursements by as much as $700 billion. Because the Medicare and states-specific Medicaid account for nearly half of the nation’s health insurance, qualitative appreciation under ACO model of care can only help off-set the Medicare cuts with incentive-based collaborative healthcare delivery.
  
  
• The compulsory implementation of EHR under the HIPAA-5010 mandate, which is likely to disrupt operational flow, consume considerable capital expenditure, as well as train or source staff to conduct EHR systems in the way that best supports patients’ privacy and security norms.
  
  
• There could be considerable change in billing and coding under ICD-10. While ICD-10 may help in streamlining the entire process of reimbursements, physicians will still have to deal with coding-specificity.
  
  
• Fee schedules will get more and more constricted under the new healthcare reforms. While Medicare and Medicaid fees schedules will set the trend of rationalized fee-schedules, it may eventually be followed by the commercial payors as well. Physicians, amidst such dual-impact, may well be forced to optimize their billing efforts to avail maximum reimbursements. And, the process of migrating to a higher system of medical billing may be costly as well as gradual.
  
  
• Under ACO care model, physicians’ reimbursements will happen through bundled fee for services. Therefore, because ACO involves coordinated services among several doctors, there needs to be systematic appropriation of reimbursements based on the involvement of each of the doctors.

While it is true that the face of adapting to the healthcare reforms may have been and likely to be impeded by the reasons highlighted above, they can still be overcome with competent services. Medicalbillersandcoders.com – which offers inclusive Medical Billing Services to a range of medical practitioners across the 50 in the US –promises to help medical practices maneuver through, and adapt effectively and efficiently to the pace of healthcare reforms.

Billing Specialists to Look After Major Billing Issues Likely to Be Faced By Radiologists in 2013

Radiologists, who have been striving to maintain a balance between diagnostic priorities and operational compliance, may well find pulled further into a host of billing and compliance issues throughout 2013:

To begin with, they will have to discern the vital connect between diagnosis coding and procedural coding systems and the systems that have evolved to provide a common method of describing diseases, diagnoses, and procedures.

Second, like in other disciplines, they may be bound by the medical necessity clause while diagnosing high-cost tests. In fact, Medicare requires that the medical necessity of high-cost diagnostic radiology tests be proved and the extent to which they may be prescribed for beneficiaries by either primary care physicians or physician specialists. Therefore, radiologists need to be aware of both the medical necessity as well as the extent to which beneficiaries are entitled for radiology reimbursement under Medicare, Medicaid, or commercial health insurance plans.

Third, admissible radiologic expenses for Part B imaging services may be rationalized on par with industry standards. As a result, radiologists may see their reimbursements dropping or appreciation depending on where they stand vis-à-vis industry standards.

More importantly, radiologists may be under increased monitoring for billing errors, and irregularities. It could even lead to being black-listed for repeated history of billing malfunction. Therefore, it may require a concerted effort to stay clear of being guilty under Medicare, Medicaid, and other HHS programs or commercial health insurance plans.

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These ensuing operational issues may prompt radiologists to:

Screen medical necessity and ask for advanced beneficiary notices (ABNs) on Medicare patients. This could require radiologists to function in tandem with the facility staff at the patient’s hospital to ensure the ABNs are accompanied by component fee as well.

Be prepared for Recovery Audit Contractors (RACs) and Comprehensive Error Rate Testing (CERTs), which are integral to standard scrutinizing. This would call for tactical and shrewd documentation and explanation of the radiologic services billed for claiming.

Evaluate templates and exam titles in accordance with the prevailing standard of equipment, technique or procedure, and the admissible CPT codes as amended from time to time.

Establish smooth communication with billing processes during revision to equipment, techniques or procedures. This would ensure that the modifications are adequately reflected in coding and billing, and claims are devoid of either under-coding or up-coding.

Make provision for reporting discrepancies, such as number of views or extent of technical complexity. This could help radiologists recover maximum claims as well as minimize the chance of denials and auditing issues

Even as radiologists seek to implement tactical moves to counter the impact of billing issues, they may find themselves swayed more towards clinical focus. That is why it makes sense to hire Radiology Billing specialists for the purpose. Medicalbillersandcoders.com – having nation-wide affiliation with a chosen pool of radiology billing specialists – offers to deploy billing resources that are competent and experienced to address and maneuver radiologists through the billing issues likely to surface in 2013.

How Radiologists Can Refine Their Revenue Cycle Management (RCM) With Radiology Billing Specialists

The emphasis on Revenue Cycle Management could never have been so high as it is now – as radiologists begin to comply with of the Affordable Care Act’s (ACA) requirements, they would realize the importance of reinvent their billing and revenue cycle management process to suit the bundled care, shared risk, and quality-driven reimbursement models. With fee-for-service likely to be phased out in favor of value-based service model, radiologists’ revenues may be vulnerable to reductions or long hold-up at the hands of either public plans such as Medicare, Medicaid, or commercial payors. In fact, the population health management requires diagnostic radiologists to adopt shared-risk model with in a period of five years or so. Therefore, radiologists will be under the obligation to coordinate and conform to performance standards for diagnostic services, rendered to both Medicare-supported beneficiaries as well as commercial insurance beneficiaries.

While displaying the requisite level of diagnostic competence may qualify them for value-based reimbursements and incentives, it is no guarantee that they automatically get converted to monetary returns unless they have substantially modified their medical billing and RCM process to the demands of value-based reimbursement model. Notwithstanding radiologists’ internal billing resources, it may not be possible to maneuver through a more regulatory payment environment without an exclusive third party diagnostic radiology Revenue Cycle Management specialist or specialists. The advantage of having such specialists onboard your Radiology Billing and RCM is that they prove catalytic in the entire process of RCM cycle, comprising:

Credentialing with inclusion of turnkey services, payer enrollment and contracting, credentialing and verification services, state medical licensing services, and personalized attention for individuals or group radiologists

Patient Access with key demographic patient information – including name, social security number, and insurance coverage – to serves as the foundation for payment of services. It is critical that this information be accurate, and linked to other billing functions from centralized registration or pre-registration systems.

Accurate and timely charge capture to make sure that all radiology services produce payable claims; it may be remembered that reconciliation of procedures-to-charges will help confirm that an accurate number of claims have been generated.

Coding powered by automatic and electronic coding of ICD-9 and ICD-10 codes, supervised by trained coders that specialize in CPT, ER and E&M coding

Billing, complete with electronic claim submission, posting denials and aggressive follow up of delays and denials

Collection with emphasis on conversion of older account receivables first and within the permissible time limit.

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As radiologists seek to uplift their revenue fortunes with Radiology Billing Specialists, Medicablbillersandcoders.com offers to mediate the employment of radiology billing specialists, who are capable of:

• Keeping reimbursements as per negotiated fee schedules with Medicare, Medicaid, or commercial health insurance carriers
• Guaranteeing payment contracts as per prevailing market
• Minimizing A/R days through complete and timely charge capture
• Enhancing payment accuracy with line-item posting of charges and payments
• Averting risk through the industry’s most comprehensive compliance program

Efficient Billing Practice to Aid Physicians amidst Continual Coding Revisions, and Avert the Possibility of Denials

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.

Even as most of the physicians have some form of in-house medical billing that addresses coding demands, the growing coding revisions and complexities require much more than simple form of in-house medical coding. It really takes an efficient medical billing management to monitor and resolve coding errors and denials. The value of such efficient medical billing management is that it can:

Renew your encounter forms or super bills and systems (where codes are stored and used for claim submission) as and when coding changes are announced.

Update physicians’ internal clinical documentation in a way that best suffices the demands of evolving coding revisions or changes.

Apply revised CPT coding guidelines to validate and minimize the risk of denials. It is noteworthy that such instant adherence to coding guidelines will naturally be appreciated by payers, which may be reflected in fewer audits and denials.

Bargain for better fee schedules based on revised reimbursement rates for the new and revised codes.

Help understand and respond to payers’ payment policies towards revised codes, establishing medical necessity of a medical service, and clinical reporting.

Employ National Correct Coding Initiative (NCCI) edits while resolve the bundling of codes.

Parallel to these comprehensive medical billing management initiatives, it could also monitor and resolve denials through:

• Payer-specific report generation of denials using Review practice management system (PMS).
  
• Discover the main reason behind denials, and resubmit claims with requisite modification and correction to codes.
  
• Supporting the applied codes with solid proof of medical necessity of medical services
  

As physicians across the U.S. seek to adapt to evolving coding revisions – of which ICD-10 alone will have 70,000 odd PCS codes, it may seem difficult without experts’ intervention.

Medicalbillersandcoders.com has effectively positioned to play the role of a facilitator during this phase of coding transformation. Our affiliation with medical billing specialists – competent and experienced to bring about systematic elevation in physicians’ coding practices – should help physicians respond to the challenges of continual coding revisions, and mitigate the possibility of denials as far as possible.

Responding To Growth-Induced Orthopedic Medical Billing Needs with Specialist Intervention

Orthopedics have been on upward growth trajectory thanks to a host of conducive factors – continued pro-orthopedic Medicare reimbursement reforms, innovative care procedures, breakthroughs in orthopedic technology and anesthesia administration have largely been responsible for upsurge in practice volumes. The combination of these factors has enabled shifting orthopedic from hospital-based inpatient form to a more popular and affordable form – outpatient or ambulatory settings. It is noteworthy that this form of orthopedic care is currently growing at over 20%, which is comparable with other fastest growing specialties.

While orthopedic practitioners have reasons to be upbeat about their practice prospects, they should equally be cautious and prepared for billing complexities that may be accompanying the swelling practice volumes.

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One of the primary reasons why Orthopedic Billing may be susceptible to billing complexities is that orthopedic comprises a broad spectrum of procedures to treat a variety of orthopedic conditions, which are perceived and valued differently by payers. Therefore, it would require orthopedic practitioners to be versatile to respond with orthopedic billing and coding in conformity with individual perception of the payer who they are submitting their claim to. More than mere submission of claims, they should necessarily have a systematic Revenue Cycle Management with comprehensive processes such as coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

Significantly, insurance underpayments, which are more rampant in orthopedic and as high as 10 to 15% of the actual claims, may push orthopedic practices into a state of revenue erosion that could jeopardize their clinical and operational efficiency. As a result, they might have to emphasize on monitoring and minimizing underpayments with an effective process of credentialing, verification, patient eligibility, and proper coding & billing.

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Coding revisions too would substantially add up to Orthopedic Billing woes – with the on-set ICD-10, orthopedic codes will be more complex, detailed, and numerically too many to code a wide array of orthopedic procedures such as bone graft, open surgical partial removal of collar bone, partial repair or removal of shoulder bone, open repair of rotator cuff, open repair of rotator cuff, reconstruction rotator cuff, open repair elbow fracture involving ulnar bone, wrist fracture pinning through skin, open surgical treatment wrist fracture, shoulder scope, repair cartilage tear, shoulder scope, partial removal collar bone, shoulder scope, bone shaving, shoulder scope, rotator cuff repair, injection of lower back joint, and many more. This monumental coding revision might warrant appointment of specialist coding professionals.

The changing orthopedic coding and billing landscape would require, among various other things,

To evaluate where you stand currently as against the projected requirements for a comprehensive orthopedic RCM comprising coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

To earmark resources to monitor finances, and assigning them the responsibility of meeting with patients before admission to pre-collect copays, deductibles and co-insurance amounts, and work out payment plans as needed.

To improve front-end revenue cycle management, comprising checking coverage and verifying patient information before hand.

To facilitate training coders on coding revisions as and when they happen.

As in the case of most busy and critical medical disciplines, orthopedics may also be bound by an overriding clinical focus that may be limiting their exposure to full-pledged orthopedic medical billing reforms. Medicalbillersandcoders.com – having successfully mediated resource-deployment for growth-induced medical billing requirements across the broad spectrum of medical disciplines – offers to replicate it in orthopedics too. With an affiliation with chosen pool of orthopedic medical billing specialists across the 50 states in the U.S., orthopedics can expect to have instant access to specialist medical billing services.

The Demands of Value-Based Reimbursement Model to Be Met With Medical Billing Specialists

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.

While Medicare and Medicaid reimbursements have already begun experimenting with ACO model as a superior form of reimbursing physicians for their services to public healthcare plan beneficiaries, commercial payers, sooner or later, too will be obliged to adopt modified versions of reimbursements. Therefore, providers will have to plan, be prepared and resourceful enough to realize their reimbursements from both public as well as commercial insurance payers.

As far as planning goes, it should all start with:

Thorough evaluation of payer market to find out what value-based payment opportunities await down the line. It may also be important to know the dynamics of payers’ reimbursement methodologies.

Assessment of your current documenting, coding, and billing practices against the requisite standards, dictated by the changing payment models.

Planning progress to the expected level through a phased manner.

Once you have the plan in place to progress to value-based payment model, providers may actually start implementation with:

Value addition to care delivery: It means minimizing the possibility of recurrence of medical conditions. When providers are able to minimize the recurrence, it would contribute to substantially savings in reimbursements that might happily shared by payers with responsible providers.

Better care coordination: Coordinated care, involving physicians and support staff will likely facilitate better clinical outcomes, which are often deemed fit for specials incentives along with regular reimbursements by payers.

Extending patient reach and engagement: When providers begin exploring opportunities to increase their and involvement, it is definitely going to improve care quality, which is the fulcrum for deciding the value-based reimbursements.

Forming new clinical alliances: The value that clinical alliances bring to clinical quality is really unquestionable and the providers’ success as value-based providers will largely depend on how best they network their clinical services with competent specialists.

As providers find themselves engrossed with value-based clinical activities, it may require a dedicated medical billing to look after the process of documenting, coding, and billing claims for value-based reimbursements.

Medicalbillersandcoders.com – with a nation affiliation with resources (medical billing specialists) that can own and execute medical billing functions on behalf of providers stuck in the process of migrating from fee-for-service model and value-based model – offers to mediate the deployment of competent, experienced and versatile medical billing specialists that could effectively look after the operational side of value-based reimbursement model while providers concentrate on the clinical aspect.

Negotiating Your Reimbursement Rates during this Phase of Payer Consolidation & Health Insurer Monopoly Power

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.

Physicians only source of revenue is from reimbursements from services they offer to patients, who may be supported commercial health insurance plans or public programs, such as Medicaid and Medicare. With most of the commercial health insurance market moving toward monopoly, physicians, mostly those practicing in small groups, are finding it difficult to negotiate adequate reimbursements. As a result, those insurers with monopoly powers are dictating the payment rates, which are often below the acceptable scale. Such unilateral administration of payments could leave physicians struggling to meet their financial obligations, obligations, including payroll, and to invest in and sustain desirable quality of medical care to their patients.

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Even the thought of accepting public insurance plans may not prove to be all that profitable – most of the patients may not have the resources to pay for out-of-pocket expenses well above the rates borne public programs, such as Medicare and Medicaid, whose rates are deemed insufficient to cover for a decent quality of medical cost. Thus, small physicians are often left with no choice but to accept rates dictated by dominant commercial insurers.

While the physicians associations have voiced strong protest against health insurer consolidations, in particular, mergers between two health insurers which threaten to create a single insurer with absolute power, it may take a while to disintegrate the trend towards a competitive market that can bring back bargaining power to physicians and patients alike. Till such time, physicians may well have to be content with rates as fixed their commercial payer. Alternatively, they can entrust their Medical Billing processes to an external entity that can use its competence and experience to arrive at as profitable a rate as possible. 

Medicalbillersandcoders.com – which has been a preferred platform for comprehensive medical billing resources – can help physicians impacted with the trend of commercial insurance consolidation. Our nation-wide affiliation with chosen pool of medical billing experts helps us to deploy resources that enhance medical billing efficiency, reduce the possibility of delay, denials, and improve practice revenues. Their expertise and experience could easily be extended for negotiating as best a reimbursement rate as possible even at this juncture of commercial payer monopoly.

Spiraling Cost of Gastroenterology Services to Warrant Billing Partner!

Despite Gastroenterology being one of the high-yielding practices, practitioners’ revenues from reimbursements continue to remain below par. This can be a distressing trend considering the spiraling cost of administering gastroenterology services. While clinical and technological advancements have brought in unimaginable precision to care, billing requirements too have become more demanding than ever before. As a result, a considerable portion of gastroenterology bills are susceptible to delays and denials, most of which are never pursued owing to incompetent billing practices. With the combined cost of such unrealized claims amounting to almost 20% of the total bills submitted, gastroenterology practices would do well to find better billing alternatives. While internal billing resources may be brought up with training and orientation, its success rate has not been all that impressive. Moreover, it could prove costly.

In view of the uncertainty over internal billing capabilities, hiring or outsourcing the entire gastroenterology billing management could prove to be a wise decision.  While the quality of outsourced gastroenterology generally happens to be good, you may still have to assess your prospective billing partners’ competence and experience against your requirements and the prevailing gastroenterology billing complexities. Primarily, your gastroenterology billing partner needs to be proficient in:

• Complex gastroenterology billing codes and rules
• Gastroenterology-related terminology
• Office notes and operative notes, coding for surgical procedures
• Code variations related to multiple procedure rules
• Denial process and appeal denied claims quickly and efficiently to ensure speedy reimbursement

The advantage of evaluating your prospective Gastroenterology Billing partner against these requirements is that it make you believe that you will be assured of comprehensive billing, collections, and practice management services, interspersed with:

• Account receivables management
• Round-the-clock claims processing
• Checking system based eligibility
• Quarterly coding updates
• System-based claims scrubbing
• Comprehensive response to all billing calls
• Regular quality assurance checks
• Weekly meetings to discuss progress and go over reports
• Customized monthly reports

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Such proven gastroenterology billing practices would invariably facilitate:

• Improved collections and income
• Accelerated payments and reduced stress
• 24/7 accessibility to your patient data and financial information
• Transparency throughout the revenue cycle
• Full financial and practice management reporting

Even as you scout for your prospective gastroenterology billing partner, Medicalbillersandcoders.com – with impeccable success in deploying apt gastroenterology billing specialists for practices across the 50 states in the US – offers a chosen pool of gastroenterology billers, adept at coding, billing, payer relations, patient relations, collections, financial reporting, fee analysis, managed-care contracts.