MEDICAL BILLING BLOG

What Does Today's (5/11/2023) End of the COVID PHE Mean for Providers?

Carl Mays, ClaimCare President/CEO — Thu, 11 May 2023 18:02:03 GMT

The Biden Administration is ending the COVID19 Public Health Emergency May 11, 2023. This blog is intended to assist you with that transition which includes important coding and billing items that will change because of the end of the PHE. Even if you believe that you are no longer involved in the treatment of or diagnostics for COVID, if you are doing any kind of remote patient care, laboratory, or Telemedicine then you will need this information moving forward. It is hard for a medical provider to be Medical Billing Experts on all relevant topics. ClaimCare is here to help.

ClaimCare Medical Billing Services has remained diligent in our billing efforts, compliance efforts, and client direction, to ensure that our clients have been reimbursed the maximum amount allowable. At the beginning of the Pandemic, we encouraged all of our clients to perform eligibility prior to services being rendered. That process should remain in place. Eligibility issues will continue to be a priority, so we encourage you to monitor that process going forward and ensure it is being fully utilized in your workflow.

Major bullet points that will impact your practice and/or COVID related business going forward:

Telehealth Services
- Telehealth services will continue to be allowed through the end of 2023. CMS expects to continue this service to Medicare Recipients as it has proven to enhance patient outcomes. Providers should continue to use CPT codes as if they were in person visits with modifier 95 to indicate services were delivered via telehealth.
- Telehealth does NOT require video beyond the pandemic if the patient does not have a smart phone or computer.
COVID Treatment
- COVID Vaccines are still covered 100% with no patient co-insurance/deductible. Do NOT use the CR modifier after May 11^th.
- COVID Booster still covered 100% with no patient co-insurance/deductible. Do NOT use the CR modifier after May 11^th.
- Treatment via oral anti-viral will continue to be covered without patient co-insurance after May 11^th Do NOT use the CR modifier after May 11^th.
- Private Insurance is required to cover Vaccines and treatment for COVID19 with no co-insurance. Do NOT use the CR modifier after May 11^th.
- Diagnosis coding for COVID related services should still utilize ICD-10 Z20822

COVID Testing
- After May 11th, all testing must be ordered by a physician or other eligible provider.
- Lab U0003, U0004, and U0005 will not be covered beyond May 11th. Revert to the usual PCR testing. You should choose the test that best describes the actual test you run.
  - Most Labs do not report a range (quantitative results) It is typically reported as a positive or negative. In this instance, it is recommended that you choose 86413 if you DO report quantitative results. If you do NOT report quantitative result, choose 86769. (this is for PCR testing only) Refer to the actual lab test that you report on to choose the closest CPT code for the test you bill.
- Labs are no longer required to report to CDC after May 11th.
- Labs are no longer required to post prices on their website for price transparency beyond May 11th.
- G2023 and G2024 will no longer be covered (lab specimen collection) beyond May 11^th.
- 99211 will no longer be utilized for specimen collection beyond May 11^th.
- Over the Counter COVID Tests will no longer be covered beyond May 11^th except for Medicaid plans. Medicaid plan members will be able to obtain OTC COVID tests through December 2023.
Miscellaneous
- Virtual Supervision stays in effect through the end of 2023.

Please reach out to the ClaimCare team if you have any questions.

ClaimCare has 30 years of medical billing experience. We have an established 100% USA-Based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2021-2022 recognition.

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete credentialing processing.

Medicare Payment for COVID-19 Vaccine Increases!

Carl Mays, ClaimCare President/CEO — Tue, 16 Mar 2021 19:31:57 GMT

For COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies and other immunizers will be $40 per dose.

This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines, and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses.

The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.

This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff.

At a time when vaccine supply is growing, Centers for Medicare & Medicaid Services (CMS) is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.

CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.

Coverage of COVID-19 Vaccines

As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance or deductible.

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.

Medicaid: State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the public health emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID-19 vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit at Toolkit.

Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost- sharing during the public health emergency (PHE). Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.

Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

More information on Medicare payment for COVID-19 vaccine administration – including a list of billing codes, payment allowances and effective dates – is available at Vaccine Shot Payment.

More information regarding the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Requirements, and how the COVID-19 vaccine is provided at 100% no-cost to recipients is available at Provider Support.

Information on the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program is available at Covid-19 Uninsured.

To view the complete Centers for Medicare & Medicaid Services (CMS) announcement, click Vaccine Payments.

To contact CMS Media Relations: (202) 690-6145 or CMS Media Inquiries.

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Reminder: COVID-19 Testing Coverage Expands

Carl Mays, ClaimCare President/CEO — Tue, 16 Mar 2021 10:00:00 GMT

On February 26, 2021, the Centers for Medicare & Medicaid Services (CMS), together with the Department of Labor and Department of the Treasury, issued new GUIDANCE that removes barriers to COVID-19 diagnostic testing and vaccinations, and strengthens requirements that plans and issuers cover diagnostic testing without cost sharing.

This CMS guidance raises some key points and a few questions that need to be inspected by Healthcare Compliance Attorneys of providers/organizations involved with testing and vaccinations. With this blog post we are providing further details about the CMS guidance and we are highlighting questions that the affected providers/organizations need to have answered by your Healthcare Compliance/Billing Attorney.

Key Points and questions:

It is critical that individualized medical necessity screens remain in place.

- This guidance document makes it clear that any testing done without “individualized clinical assessment” would be considered either public health surveillance or a job requirement and would not be required to be paid by insurance companies.

It is critical to get the interpretation of these new guidelines from a healthcare compliance and billing legal expert because there are some unclear areas in the guidelines. Specifically:

- On the one hand, the document says that payers cannot deny coverage of a COVID-19 test for lack of medical necessity. On the other hand, they say that payers must assume when they receive a claim that it reflects an "individualized clinical assessment." This seems to imply there has in fact been a medical necessity determination by a medical provider.
  - If an "individualized clinical assessment" does imply the presence of a medical necessity, then how does the example of "I want to be sure I am COVID-19 free before seeing my parents" require such assessments to be modified so that a COVID-19 test is approved for reasons of this nature?
- The document seems to emphasize the importance of an individual seeking the test vs the test being required for Public Health Surveillance or employment. How does the distinction between a test being required interact with medical necessity of a test that is determined via an “individualized clinical assessment?”

- - If I am seeking a test because I need to show clear results to attend an optional event like a ballgame, a concert, a visit to a nursing home, a cruise, etc., then if prior to testing I have an “individualized clinical assessment” (e.g., a screening questionnaire), does that meet the criteria for a billable test since I am seeking the test so that I can attend an optional event AND I am receiving an individualized screening for medical necessity? These examples seem extraordinarily similar to the specific example given by CMS of an asymptomatic person with no know exposure having the COVID-19 test covered because the person wants to visit a parent or relative.
  - If I need to have a clear test for my job AND I have an individualized medical necessity screen applied, is there any reason that the test cannot be billed to insurance if I show medical necessity through this “individualized clinical assessment?” Prior to this CMS clarification, payers had to cover a COVID-19 test when a medical necessity screen based upon symptoms or potential exposure warranted it. Does the fact that in some situations, such as “I want to visit my parents,” traditional medical necessity based upon symptoms or exposure risk seems to no longer be a requirement mean that a medical necessity screen can no longer be used to justify insurance billing of employee tests justified by exposure or symptoms and ordered via an “individualized clinical assessment?” In other words, has the medical necessity screen lost importance in determining if you can or cannot bill insurance for employees?
- Does any of this impact the wording of agreements that might be put in place with organizations requesting testing to help to ensure the language in the agreement does not run afoul of any of the public surveillance and employment testing exclusions?

More Detail behind the points and questions above:

There are a few key areas on the CMS guidance document that prompted the questions I outlined above. As you can see on the document, there are 13 questions that are asked and answered. I spotlight Question 2 and the answer supplied by CMS:

Q2 – May plans and issuers distinguish between COVID-19 diagnostic testing of asymptomatic people that must be covered, and testing for general workplace health and safety, for public health surveillance, or for other purposes not primarily intended for individualized diagnosis or treatment of COVID-19?

Answer – Yes. Plans and issuers must provide coverage without imposing any cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements for COVID-19 diagnostic testing of asymptomatic individuals when the purpose of the testing is for individualized diagnosis or treatment of COVID-19. However, plans and issuers are not required to provide coverage of testing, such as for public health surveillance or employment purposes. But there is also no prohibition or limitation on plans and issuers providing coverage for such tests. Plans and issuers are encouraged to ensure communications about the circumstances in which testing is covered are clear. To the extent not inconsistent with the FFCRA’s prohibition on medical management, plans and issuers may continue to employ programs designed to detect and address fraud and abuse.

This is the section that prompts the questions about whether “individualized screening” moves a test form the public surveillance realm to the covered test realm. The concern is whether loosening the “medial necessity” guidelines apparently to allow individuals to have covered COVID-19 tests for any reason they deem necessary impacts the weight “individualized screening” has held in relation to COVID-19 testing up to this point in terms of justifying billing based upon medical necessity.

The answer below to Q1 in the guidance document is what creates the uncertainty between the purpose of “individualized clinical assessment” when reasons such as “visiting my parents” now are covered for testing.

“When an individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, or when a licensed or authorized health care provider refers an individual for a COVID-19 diagnostic test, plans and issuers generally must assume that the receipt of test reflects an “individualized clinical assessment” and the test should be covered without cost sharing, prior authorization or any other medical management requirements.”

This statement is also what makes it critical that you have a screening that results in a "yes" where a doctor orders the test or a "no" where a doctor does not order the test. As long as the doctor does not order test for people that do not pass the screen then it should fall under the “individualized clinical assessment” point made above.

Finally, the document also emphasizes the importance of an “individualized clinical assessment” when it says test must be covered "...when a licensed or authorized healthcare provider administers or has referred a patient for such a test."

Conclusion:

Obviously, this blog post poses more questions than it does clear guidance. However, as has been the case from the beginning of COVID-19, these situations are unprecedented. As such, the devil is in the “legal details.”

I would argue that all of this guidance means:

Medical necessity is still required,
The scope of medical necessity has expanded, and
As long as an individual screening for medical necessity is used, individuals meeting the new medical necessity guidelines are billable to insurance.

What is far from clear is exactly how this guidance specifically expands the definition of “medical necessity.”

Thus, as emphasized in the beginning of this blog post, it is critical to obtain your Healthcare Attorney’s opinion on all the points and questions outlined in this post and in the CMS GUIDANCE document.

About ClaimCare ®

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

100% USA-Based HIPAA-Compliant Medical Billing Company

CMS Seeks Faster COVID-19 Lab Results

Carl Mays, ClaimCare President/CEO — Fri, 16 Oct 2020 17:03:10 GMT

CMS Seeks Faster COVID-19 Lab Results

CMS is working to ensure that patients who test positive for the virus are alerted quickly so they can self-isolate and receive medical treatment. Thus, under President Trump’s leadership, the Centers for Medicare & Medicaid Services posted an October 15 announcement of new actions to pay for expedited COVID-19 test results.

Back on April 15, CMS Administrator Seema Verma announced, “CMS has made a critical move to ensure adequate reimbursement for advanced technology that can process a large volume of COVID-19 tests rapidly and accurately.” At that time, Medicare payment to laboratories for high throughput COVID-19 diagnostic tests was increased from approximately $51 to $100 per test.

Now, to encourage labs to increase the rapidity in receiving results, beginning January 1, 2021, Medicare will pay $100 only to laboratories that complete high throughput COVID-19 diagnostic tests within two calendar days of the specimen being collected. Medicare will pay a rate of $75 to laboratories that take longer than two days to complete these tests, effective also on January 1, 2021.

“As America continues to grapple with the COVID-19 pandemic, prompt testing turnaround times are more important than ever,” said CMS Administrator Seema Verma. This updated payment announcement “supports faster high throughput testing, which will allow patients and physicians to act quickly and decisively with respect to treatment decisions, physical isolation, and contact tracing. President Trump continues to lead the most robust testing effort anywhere in the world.”

Amended Administrative Ruling (CMS 2020-1-R2)

This amended ruling, effective January 1, 2021, lowers the base payment amount for COVID-19 diagnostic tests run on high-throughput technology from $100 to $75 in accordance with CMS’s assessment of the resources needed to perform those tests.

Then, Medicare will make an additional $25 add-on payment to laboratories for a COVID-19 diagnostic tests run on high-throughput technology if the laboratory: (1) completes the test in two calendar days or less, and (2) completes the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month.

HCPCS Code U0005

CMS established these requirements to support faster high throughput COVID-19 diagnostic testing and to ensure all patients (not just Medicare patients) benefit from faster testing. These actions will be implemented under the amended Administrative Ruling (CMS-2020-1-R2) and coding instructions for the $25 add-on payment (HCPCS Code U0005) released October 15.

According to CMS, “The new payment amounts effective January 1, 2021 ($100 and $75) reflect the resource costs laboratories face for completing COVID-19 diagnostics tests using high throughput technology in a timely fashion during the Public Health Emergency."

Impact on Laboratories

This CMS update may have an impact on laboratories’ logistics and/or sample collections beginning with dates of service from January 21, 2021, forward. Please note that the two-day clock starts when the sample is COLLECTED, not when it is received by the lab.

It appears this updated policy is measured on a monthly basis. The two scenarios seem to be:

1. In the prior month, the lab completes the majority of ALL COVID-19 tests (across all payers, not just Medicare) in 2 days or less from sample collection, and the two codes are billed:
a. COVID-19 test (U0004), which will pay $75
b. Fast completion code (U0005), which will pay $25

2. In the prior month, the lab does not complete the majority of ALL COVID-19 tests (across all payers, not just Medicare) in 2 days or less from sample collection, and the one code is billed:
a. COVID-19 test (U0004), which will pay $75

Questions Will Be Asked

Undoubtedly, laboratories will have questions regarding this updated policy, and I feel sure additional information will be coming from CMS to answer such questions as:

What does “majority” mean? Simple majority? Super majority?

Do both the test being billed AND the majority of tests from prior months need to be completed in two days or less? If you visit the CMS source, the text is not clear on this point.

What if the issue is with the sample source and not with the lab when it comes to missing the two-day mark?

When ClaimCare uncovers more information regarding this updated policy, we will posting it via our blogs.

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ClaimCare has 30 years of medical billing experience. We have an established 100% USA-based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to ClaimCare clients.

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COVID-19 CPT Code Update

Carl Mays, ClaimCare President/CEO — Fri, 25 Sep 2020 10:00:00 GMT

Just in case you are not already aware, this memo is to inform you the American Medical Association (AMA) added Current Procedural Terminology (CPT) code 99072, effective September 8, 2020, and has updated information about this code and other codes, which was posted September 22, 2020, on the AMA website in an article titled COVID-19 Coding and Guidance.

Coming rather late in the COVID-19 crisis, this code regards “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service when performed during a Public Health Emergency as defined by law due to respiratory-transmitted infectious disease.”

CPT Code 99072 Explained

The earlier announcement explained Code 99072 is used to report additional practice expenses necessary in an office visit or other non-facility setting to mitigate the transmission of the respiratory disease for which the Public Health Emergency (PHE) was declared. These expenses include, but are not limited to, additional supplies such as face masks and cleaning supplies, as well as clinical staff time for activities such as pre-visit instructions and office arrival symptom checks that support the safe provision of evaluation, treatment or procedural services during the respiratory infection-focused PHE.

Instructions state that when reporting 99072, report only once per in-person patient encounter per day, per provider identification number, regardless of the number of services rendered at that encounter. Code 99072 may be reported during a PHE when the additional clinical staff duties as described are performed by the physician or other qualified health care professional in lieu of clinical staff.

Dollar Value To Be Established

This new code does not yet have any dollar value associated with it, but efforts are underway to establish payment.

CPT Code 86413 Also Approved

As explained in the update, the AMA also approved CPT code 86413, which regards “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative," in response to the development of laboratory tests that provide quantitative measurements of SARS-CoV-2 antibodies.

Per the standard early release delivery process for CPT codes, note that the code descriptor will need to be manually uploaded into electronic health record systems. In addition to the long descriptor, codes 99072 and 86413 have short and medium descriptors that can be accessed on the above mentioned AMA Website.

For more detailed information on reporting codes 99072 and 86413, please refer to the September Update article on CPT Assistant, the official source for CPT coding guidance.

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The Rise and Fall of Offshore Medical Billers

Carl Mays, ClaimCare President/CEO — Thu, 13 Aug 2020 10:00:00 GMT

A trend began several years ago for practices to move billing and coding offshore to save money, which has often led to crippling the practices rather than adding any advantage in terms of being more effective, efficient and productive. And money has often been lost rather than saved.

A January 2019 “For The Record” article titled Is Offshore Coding Dead in the Water? tells of a two-year study involving six hospital systems. In an apples-to-apples comparison of USA coders and offshore coders, the offshore coders were less accurate and productive than the USA coders. There was a higher denial rate and lower reimbursement resulting from a lower case mix index. Additionally, offshore coders required longer onboarding.

In the end, the savings realized from employing lower-wage offshore coders was lost to productivity issues and lower reimbursements. All variables considered, offshore coders cost hospitals $3.10 per hour more than their American counterparts.

The study, which was presented in detail at the 2018 American Health Information Management Association (AHIMA) Convention was the first of its kind, and it appears the findings are the first solid numbers supporting a move away from offshore coding solutions. However, warnings from various sources existed long before the study was begun. Law firms, healthcare organizations, publications and IT groups were among those sounding alarms.

Offshore Medical Billing Poses Security, Legal Issues

As far back as 2012, the Liles/Parker Law Firm, which specializes in Healthcare Law, warned of security and legal issues arising from the use of offshore groups in an article titled Overseas Outsourced Billing and Coding – Compliance Risks. The article opens with, “Thinking of sending your medical billing and coding functions out of the country? You better think twice. While overseas outsourced billing is growing in popularity for medical office functions, this practice represents a unique set of problems for both physician practices and 3rd party billers. And the news is just getting worse." Some points made in the article include:

You have no guarantees that a coding and billing business overseas is HIPAA compliant or even understands the law at all.
Providers are responsible not only for their practice, but also for the acts of their business associates and their respective subcontractors overseas.
Obtaining a judgment against an offshore entity is next to impossible, takes a substantial amount of time, and costs a lot of money.
Liles/Parker writes, "We had previously reported that the backlog for having a case heard in India was nearly 20 years. But recent estimates by the National Bar Association of India put that figure closer to 350 to 400 years."
Offshore workers have extorted providers over PHI records. In one case, an employee of a Pakistan billing company contacted the hospital on whose records she was working. She demanded a significant sum of money from the hospital or she would release the medical records on the Internet and anonymously contact United States authorities. Given the legal case backlog information above, the hospital had no option but to pay.

Supreme Court Stepped In After Liles/Parker 2012 Article

The 2013 HIPAA Omnibus Rule prevents medical providers from enforcing HIPAA laws in foreign countries. Providers are responsible for improper disclosures and breaches with business associates and their respective subcontractors overseas. Thus, if a provider offshores billing or EMR the provider is responsible for all HIPAA fines, which could be as much as $10,000 per violation.

There are some so-called "USA-based" medical billing companies that have home offices in America, but offshore the majority of their work. These companies are dependent upon their foreign workers, but as American companies they have to answer to their clients when problems arise offshore.

Publications Report Offshore Horror Stories

A 2013 "Fierce Healthcare" article titled 32,000 Patient Records Exposed On Contractor's Unsecured Website tells of a Tennessee-based hospitalist and intensivist group that contracted with an India company to transcribe care notes dictated by physicians. The contractor was supposed to store protected patient health information on a secure website, but its firewall was down between May 5 and June 24 before the Tennessee group discovered the problem.

Health information on 32,000 patients across 48 states was exposed. Compromised patient information included patients' names, dates of birth, diagnosis description, treatment data, medical history and medical records numbers. According to U.S. Department of Health and Human Services records, it was the second HIPAA breach for the Tennessee group.

The article reports that according to the Ponemon Institute, considered an eminent research center dedicated to privacy, data protection and information security policy, 94% of 80 participating healthcare organizations polled had experienced at least one data breach that they were aware of in the previous two years. Those breaches cost organizations a total of $6.78 billion annually.

IT Companies Warn Against Overseas Medical Billers

Scouring the Internet for multiple IT company remarks on offshore medical billing and coding, here are some summarized views:

There are always dangers of HIPAA security breaches and violations of patient privacy, but these dangers are intensified with offshore contractors, and immediate fixes are less tenable.
Many offshore companies utilize a “bait-and-switch” technique. Initial workers assigned to you are what the company considers as their “best.” Later, these “best” are replaced by the company’s lowest-paid, inexperienced workers who use the login of the original worker. Errors increase, productively drops, and security suffers.
Low-paid offshore workers are enticed to commandeer ePHI (as referenced in the Liles/Parker information above). Such tactics provide a much greater risk than any possible savings afforded by cheap offshore work.
Offshore contractors may present a basic package of service, but then charge extra for services that are already bundled in initial agreements by a truly 100% USA-based company like ClaimCare.
Turnover rate is much higher offshore because employees are always looking for higher-paying jobs, whereas ClaimCare emphasizes medical billing "careers" rather than jobs. One of the things that entices quality people to seek employment at ClaimCare is the emphasis on personal growth opportunities within a company that grows annually.
Surveys have shown that offshore workers are less experienced than USA-based workers and have little or no understanding of America's complex and everchanging federal and state laws regarding healthcare.
In general, without taking into account Daylight Savings Time, the time in India (which has only one time zone) is 10.5 hours ahead of USA central time. (The half-hour aspect arose when the meridians for the Indian subcontinent were created. New Delhi was in between the two and India chose to be 30 minutes between the two time zones.) This time element, along with the language element, affects client and patient contacts to a large degree. It also limits real-time access to patient accounts and revenue cycle management reports.
Whereas ClaimCare can work on clients' systems or its own, offshore contractors often work only on their own, which leads to lack of transparency in reports and data such as payment posting, collection efforts, charges, third-party payer claims and more.

Groups Push Congress to Delegitimize Offshoring

Some USA-based groups are pushing Congress to strengthen the HIPAA laws by making offshore medical billing illegal. One such letter to Senators and Representatives contains:

"A foreign workforce is not accountable to the HIPAA laws, and since the HIPAA laws cannot be enforced overseas, we ask that you protect us by keeping medical billing within the United States. In addition to the security that comes with a USA-based labor force being held accountable to HIPAA laws, this move would also keep medical billing jobs in America. We need your presence in Washington to create and pass legislation that safeguards our sensitive data and preserves the medical industry. Do not work so hard to create safeguards within HIPAA only to see them undermined by offshoring."

ClaimCare Rescues Providers, Facilities from Offshoring

With deep knowledge of offshore billing issues, ClaimCare steps in with distinctive elements and nuances as a professional medical biller to solve the majority of problems that result from the offshore billing and coding model. In doing so, ClaimCare brings unique solutions that are designed to support effective communication, offer up-to-date healthcare intelligence and security, deliver the right information at the right time and fulfill our mission “To collect the maximum amount for your practice as fast as possible while helping to alleviate costs and hassle for your organization.”

About ClaimCare ®

ClaimCare has once again been named a Top 10 Medical Billing and Coding Company. The honor this time comes from "MD Tech Review." The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition.

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

100% USA-Based HIPAA-Compliant Medical Billing Company

Provider Relief Fund Deadline Extended to August 3

Carl Mays, ClaimCare President/CEO — Mon, 27 Jul 2020 10:30:00 GMT

Provider Relief Fund Deadline Extended to August 3

It’s not too late to apply for financial emergency assistance from the Provider Relief Fund if you have not yet done so. The deadline to apply has been extended to Monday, August 3.

For in-depth information from HHS about this extension, visit CARES Act. Included with the latest update on the application process is information about a webcast on Monday, July 27, 2020 at 3:00 p.m. ET.

You may also want to revisit an earlier ClaimCare blog concerning Four Options to Boost Your Practice’s Cash on Hand Balance.

Another site of interest in this matter is HealthCare Law Diagnosis.

Meanwhile, we have discovered through our clients that some patients, especially senior adults, remain hesitant about going into a medical office or facility since COVID-19 is on the upswing in certain areas.

Therefore, being proficient in telemedicine is still highly important. We have posted several earlier blogs regarding telemedicine, which include:

Keep Revenue Flowing During Pandemic (03-27-20)

Serving Patients Through Telemedicine (03-31-20)

Update to Telemedicine (04-03-20)

Also, regardless of the state in which you have your practice or facility, here is an informative and very extensive article by the Texas Medical Association about telemedicine and more.

About ClaimCare ®

ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition.

For more information, phone (855) 376-7631 toll-free, or contact sales@claimcare.net, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

100% USA-Based HIPAA-Compliant Medical Billing Company

Insurance Payers Moving at Snail-Like Pace

Carl Mays, ClaimCare President/CEO — Thu, 16 Jul 2020 19:45:51 GMT

We are posting this blog for ClaimCare clients and for other medical practices and facilities who have not yet become clients. During this continuing COVID-19 pandemic, we want to proactively explain to all in the healthcare industry why your Account Receivables may be behaving differently than anyone would expect.

In a previous blog I shared how ClaimCare spent significant time, energy and money putting in place a fully-tested, HIPAA-compliant work-from-home option several years ago following a flu season that hit ClaimCare and the nation hard.

Thus, we are one of the relatively few companies with no interruption or slowdown whatsoever in serving our clients in a timely and responsible manner. This cannot be said about many insurance payers.

Even though ClaimCare has been working our clients’ ARs consistently and hard throughout the COVID-19 pandemic, we are not getting the results these efforts would normally yield. This is because many payers entered the crisis unprepared and are now woefully understaffed.

Anything that requires “human intervention” in order to resolve appeals and other forms of claims reprocessing is taking much longer than normal. Some of our clients’ ARs have not decreased over the past three months as much as we normally are accustomed to seeing due to bottlenecks caused by payers. For example:

With one very large payer that we can normally call and have a claim put back into reprocess on the same day, we now have difficulty in even conversing with a human.
Medicare appeals normally take about 30 days to resolve, but now we have claims in appeals from March that still have not processed due to Medicare staff shortages.
We left multiple messages for the Supervisor of one Medicare Advantage group, and when she finally returned our call she said, “We are doing the best we can, but we can’t give you an update yet on your appeals.”

ClaimCare continues to be very aggressive with these payers within the constraints of an unprecedented event limiting their staffing. We have found chains of command to be very thin and the Insurance Commissioner unable to get involved with pandemic-related slowdowns. We will eventually obtain what is due to our clients because we feel our 100% USA-based team is the best, most professional and most prepared to get the job done.

If anyone reading this blog post – client or non-client – has any specific questions or concerns regarding this current situation, please don’t hesitate to contact us. We in the healthcare industry are all in this together, working to achieve the best for patients, practices, facilities and America.

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Let’s Take A Look At Medicare Allowables

Carl Mays, ClaimCare President/CEO — Wed, 17 Jun 2020 10:30:00 GMT

A new healthcare provider of medical appliances who turned to ClaimCare for billing and other matters was confused about Medicare Allowables. The primary question this provider had was, "What will I collect from Medicare for my services?"

This provider was confused because sources had been saying that Medicare only pays 80% of the published rate. In a way, this is true. However, as more established healthcare providers know, it's not the whole story.

Original Medicare publishes the allowable amounts for a given Current Procedural Terminology (CPT) code. How much of that specific procedure Original Medicare pays depends on where a patient is in meeting his or her deductible for the year. According to the Center for Medicare and Medicaid Services (CMS), the annual deductible for all Medicare Part B beneficiaries in 2020 is $198.

If a patient has Original Medicare only (with no additional Medicare-related plan, which we’ll cover later on in this post) and has not met any of the deducible, the patient is responsible for that $198 plus the remaining 20% of the procedure cost. As you can imagine, with such a small deductible, Medicare patients tend to meet it early in the year.

Once an Original Medicare patient has met the deductible, the patient will owe 20% of the allowed amount and Medicare will pay the other 80% of the allowed amount. For example, if you billed a code that would allow $100 and the patient had met the deductible, you would get a payment of $80 from Medicare and be told to bill the patient for the other $20.

ClaimCare would then send the patient a bill. If not duly paid, ClaimCare would follow up with a call and, if needed, a collection letter. I imagine your next question would be, ”How much of the patient’s balance will we likely collect?” The answer is, “It depends.” Assuming the patient has only Original Medicare, it depends on some following factors:

1. Patient-population Demographics.

1. If you are in a financial area with a middle-class population or higher, we would expect to collect around 85% to 90% of the patient balances owed. This demographic tends to pay bills and to be concerned about credit scores.
2. At the other end of the spectrum, offices with many Medicare patients who have Medicaid as a secondary insurance will result in almost no patient payments. This is because when Medicaid is secondary to Medicare they will tell us that Medicare has already paid more than Medicaid would allow. Thus, Medicaid will not pay the balance and you cannot bill the patient. This also applies to patients who have Medicaid as the primary insurance. You must accept only what Medicaid allows for these patients. You cannot bill a Medicaid patient.
3. As I am sure you can see, the more you trend away from the regions described in category (a) above and toward category (b), the less your patient collections yield will be. If you are providing the patient with something that costs you, such as some appliance or test, you could consider requiring the patient to provide you a credit card number when the appliance or test is ordered. You could charge the expected amount the patient will owe before you provide the extra appliance or test. If you are a ClaimCare client, we could help you update your form with the info needed to do this. If it ends up the patient owes less than charged, then you could refund what was overpaid. If too little was paid, you could charge the credit card for the rest. We could help with this in our patient services area. However, keep in mind: You cannot do this for Medicaid patients.

2. Typical size of the balance you will be owed.

It is best that the balance owed by a patient not be too big or too small. You want it to be in the Goldilocks Zone (just right). Balances that are really small (less than $10) can be a problem because people don’t want the hassle of making a call or writing a check to pay such a small balance, and most folks know that balances this small will not impact their credit report. On the other hand, if you get balances that are in the hundreds-of-dollars range, patients may be trying to avoid paying simply because they cannot afford such a big balance.

Of course, ClaimCare creatively presents payment plans to these patients with large balances, empathizing with them, but emphasizing the importance of making payments at a rate they can afford. Balances in the $10 to $200 zone are in the Goldilocks Zone. I am not saying ClaimCare will not collect payments outside this range. I am just saying the yield is best in the Goldilocks Zone.

Will they even owe money?

The additional Medicare-related plans to which I referred earlier will sometimes cover 100% rather than just 80% of the bill. They will also sometimes cover things that traditional Medicare will not pay. This is why getting into these plans is important. The percentage of people who have these plans has continued to grow exponentially, especially among patients in category (a) under the Patient-population Demographics above. Most practitioners and facilities are already familiar with such plans, but for the sake of information for newer providers, and review for experienced providers, here are some at-your-fingertips links to give insights into the various plans and terminologies:

Medicare Advantage Plans

Medigap Plans

Medicare Supplement Insurance

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April 3, 2020 Update to Medicare Telemedicine Notification

Carl Mays, ClaimCare President/CEO — Fri, 03 Apr 2020 22:29:15 GMT

April 3, 2020 Update to Medicare Telemedicine Notification

At 2:45 this afternoon, CMS notified all providers via Special Edition Message that CMS has made yet another change in the coding requirements for Telemedicine/Telehealth services. Pointed out below are the most critical changes, which pertain to place of service and modifier utilization. Here is the original April 1 Telemedicine Blog Post that contains the earlier CMS information to which we are now referring. Comparing the April 1 blog to this updated blog will make things less confusing to you.

04-03-20 Revised Special Edition Telemedicine Message from CMS

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. We will notify you when those services are clearly identified.

For professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), telehealth claims need to be billed with:

Place of Service (POS) equal to what it would have been had the service been furnished in-person. This means you no longer use the 02 Place of Service.
Modifier 95, indicating that the service rendered was actually performed via telehealth.
As a reminder, CMS is not requiring the CR modifier on telehealth services.

For telemedicine claims already billed with the “02 Place of Service,” medical billers actively monitoring these claims should show them as having been received and in process. So, it appears this updated change will only impact claims from today forward. Your medical biller should notify you if they find any problems with older or new telemedicine claims.

ClaimCare remains on top of all things that impact practices and will continue to monitor these updates. You may have numerous resources sending information to you. Make sure your medical biller vets every piece of information that is sent to you to ensure its validity.

We certainly hope you and your staff are staying safe and healthy during this crisis. We encourage you to share with everyone, staff and patients alike, that they can keep updated on the news and recommendations on the government’s Coronavirus.com website.

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For additional information, contact sales@claimcare.net, or phone toll-free (855) 376-7631, or visit the ClaimCare Medical Billing website. We can assist your practice and/or facility in numerous ways.