<img alt="" src="http://www.poiuy12.com/102832.png" style="display:none;">
    Welcome to the ClaimCare Medical Billing Blog. We strive to provide content that improves the overall quality of medical billing efforts across the US. If you have any specific topics that you would like to see addressed in this medical billing blog please post the topic in the Medical Billing Questions & Answers Forum. If you have an article that you would like considered for publication in the medical billing blog then please email your article to resources@claimcare.net.


    3 Data Analytics that Should Always Be Included in Your Medical Billing Report

    Posted by Carl Mays on Wed, Sep 11, 2019 @ 03:00 PM

    3 Data Analytics that Should Always Be Included in Your Medical Billing ReportMedical billing reports are important in evaluating the efficiency of your practice. Thus, reports should show the performance of your organization in full details. This will greatly help in improving your revenue cycle.




    Some of the questions reports should be able to answer include:

    • Referring physician profitability
    • Front desk employee effectiveness
    • Payer contractual compliance
    • Provider productivity
    • Coding profiles

    How is this possible? Read on to know the different data analytics that should be present in your medical billing report.

    1. Accounts Receivable Aging Report

    This report contains any accounts receivable (A/R) that remain to be paid by the insurance companies. It also reveals how long A/R has been unpaid and the average time a claim needs before it is paid by the insurance provider.

    As an example, for CIGNA HealthCard holders, Cigna says they do their best to process medical claims within 5 days after filing.

    Five days may not be possible, but medical claims should be paid in less than 45 days. Thus, any claim that extends beyond 45 days to be paid should immediately be monitored. If this reaches 90 days, then it is a red sign that you should urgently take action with it.

    As a friendly note, you should also consider the type of claim you are requesting. Generally, the following claims take longer to be processed:

    • Workers compensation
    • Car accident claims
    • Out-of-state claims

    Thus, it is best to be mindful of any healthcare services provided under this category.

    2. The Key Performance Indicators (KPI) Report

    Just like any business, your practice should know the most profitable procedures in your organization. Thus, your key performance indicator report should be able to track the following:

    • Frequency a procedure is performed
    • Sum charges and collection
    • Total adjustments
    • Outstanding A/R

    This should be neatly presented in a document so you can easily compare results on a per-date basis. Any sudden surge or leap in weeks or days should be carefully noted so you can monitor these dates more meticulously.

    3. The Insurance Analysis Report

    This lists the top payers and insurance companies contributing to your practice, based on the collection per Total Relative Value Unit (RVU).

    But what exactly is an RVU?

    This represents the following components:

    • Physician work expenses: 52%
    • Practice expenses (staff, facilities, overhead): 44%
    • Malpractice expenses: 4%

    It is further influenced by the area of the country in which the service is provided. This, together with the above components, comprises the total RVU of a particular service.

    Why is this important for your practice?

    Knowing the collection per total RVU of your procedures gives you the leverage to negotiate for better pricing with various insurance companies.

    How do you know if you are making a smart negotiation?

    Ideally, the collection per Total Relative Value Unit should be higher than the current Medicare Conversion Factor, which is $36.04. If this is lower, then you are not collecting the right amount for your services.

    Check who among your payers are paying less and start talking to them about it. If they will not settle with an agreement, then it may be better to drop them and add another carrier that pays better. However, be extra careful before dropping one of your carriers because it may have an impact on your practice.

    For better results, seek the advice of experts in the field of medical billing and coding to help you make an assessment of your current medical billing reports.

    Do you wish to know more about medical billing and coding practices? Subscribe to our blog for more helpful insights or complete our online form so we can schedule an appointment with you. You may also contact us at (855) 376-7631.

    About ClaimCare

    ClaimCare delivers medical billing and coding reports with detailed information for you to fully understand the state of your practice. This helps your organization to create action plans that can help improve your performance. It also comes with an easy-to-use dashboard reporting system, which easily presents critical information in a comprehensive manner.


    Tags: medical billing, medical billing resources

    Rejected Medical Claims vs Denied Medical Claims: What's the Difference?

    Posted by Carl Mays on Tue, Sep 10, 2019 @ 03:20 PM

    Rejected Medical Claims vs Denied Medical Claims_ Whats the DifferenceLooking back, to look ahead: With ICD-11 on the horizon for 2022, Centers for Medicare & Medicaid Services (CMS) reported in 2015 that claims were processed with fewer rejected and denied claims after the transition from ICD-9 to ICD-10. Rejections and denials are projected to decrease even more when ICD-11 takes effect.

    Meanwhile, while dealing with ICD-10, many providers are confused on how to differentiate “rejected” medical claims from “denied” medical claims. This article discusses how you can distinguish the two from one another and steps on how to avoid both.

    What are rejected medical claims?

    These medical claims are considered unpayable and are sent back by the payer due to:

    • Incorrect information
    • Failure to meet specific data requirements
    • Non-adherence to the required formatting

    Due to these reasons, rejected medical claims are not even entered into the computer systems of payers. Thus, they cannot be processed.

    Once the error has been fixed, rejected claims can be submitted for approval. Thus, it is important for your medical biller to properly code and complete the information required by the payer.

    How are denied medical claims different from rejected medical claims?

    Unlike rejected medical claims, denied claims have been received and processed by the payer, but considered unpayable. Although these claims can be resubmitted, it should be done with a reconsideration request or appropriate appeal. Otherwise, it will just be denied once again costing your practice or facility more time and money.

    What causes a medical claim to be denied?

    Several factors can result in a denied medical claim. This includes:

    • Incorrect patient identifier information
    • Termination of medical insurance coverage
    • Requirement of prior authorization or precertification
    • Excluded or non-covered services
    • Requires supplementary medical records
    • Auto or work-related incident
    • Invalid CPT or HCPCS codes
    • Lapse of the filing date
    • Lack of referral on file

    Thus, make sure your medical billers and coders are knowledgeable regarding the latest medical coding updates and are skilled in properly preparing your medical claims. Otherwise, you’ll have instances of medical claims being denied and rejected by the payers.

    How can you improve your practice’s claim rejections and denial rates?

    There are several ways to improve your claim rejections and denial rates:

    1. Analyze and track your payer denial and rejection trends

    Review the most common types of mistakes and coding errors committed by your medical billing team. Create routine chart audits for documentation and data quality. Based on this information, create a course of action that will minimize, if not eliminate, these errors.

    2. Educating your medical billing and coding staff

    Invest in training your staff. Provide training on how to handle claim denials and rejections appropriately.

    Otherwise, consider outsourcing your medical billing to an “Experienced” and ”Knowledgeable” medical billing company. In this manner, you are guaranteed that the team handling your medical billing is well equipped, skilled, and knowledgeable in completing these tasks.

    3. Discuss your concerns with payers

    Schedule an appointment with your payers. Discuss, revise, or eliminate contract requirements resulting in denied claims, which eventually get overturned after an appeal. This helps to clarify the requirements in order to avoid future medical claim rejections.

    Are you having problems with your medical claim submissions? Do you need help processing these claims? Subscribe to our blog for more tips and updates.

    About ClaimCare

    ClaimCare has more than 25 years of experience in providing medical billing and coding services to various practices. Throughout these years, they have helped numerous organizations increase their revenue cycle by eliminating medical claim rejections and denials. Complete our online form or call us toll-free at (855) 376-763 to learn more about the services we deliver.

    Tags: medical billing, medical billing services, medical billing resources, clean claims

    4 Steps to Painless Physician Credentialing

    Posted by Carl Mays on Thu, Sep 05, 2019 @ 10:00 AM

    4 Steps to a Painless Physician CredentialingThe famous Chinese philosopher Confucius once said, "A man who does not plan long ahead will find trouble at his door." This is true, especially with healthcare providers in the U.S. and their physician credentialing process.

    In a study conducted and published by the Beckers Hospital Review, it has been revealed that a one month delay in physician credentialing can result in a $30,000 loss in revenue. This amount further increases for higher billing specialties such as cardiothoracic surgery and orthopedics. Thus, it is important for healthcare providers to plan properly for their physician credentialing procedure to ensure their cash flow will run smoothly in 2019.

    These steps will help you organize your physician credentialing process:

    Step 1: Start Early

    Physicians Practice, an online publication, said that most physician credentialing can be done within 50 to 90 days, but it is best to give your practice a 120-day leeway. This is because the internal timeline of the payer who processes the application varies, differing from one payer to another.

    Given this timeframe, it is best to start your physician credentialing process earlier, preferably prior to hiring.

    Step 2: Pay Attention to Detail

    Perform the necessary due diligence when submitting your application.

    Many physician credentialing delays are caused by incomplete and incorrect information. This is a simple mistake that can cost you a huge sum of money. Thus, it is important for your team handling the physician credentialing process to pay close attention to all of the required information.

    Double check to see if all of the entries have been properly filled out. In doing so, you'll have a more efficient physician credentialing process, which means completing it within 50 to 90 days. Plus, you avoid going through the process of re-applying.

    Step 3: Remain Updated with the Coalition for Affordable Quality Healthcare (CAQH)

    In December 2018, CAQH announced new functionality for Verifide ™, This automated solution verifies the accuracy and completeness of credentialing information submitted by healthcare providers to health plans.

    This will now become the primary source verification (PSV) as it offers real-time visibility into your credentialing application status. As a result, your practice will have an easier time knowing the reason behind your physician credentialing rejection or denial.

    Thus, you should always be in the loop with the latest updates provided by CAQH.

    Step 4: Be Knowledgeable with State Regulations

    State regulations vary from one another. For some states, a physician credentialed by Provider A in another state may be streamlined in their states; others may allow a physician to avoid the full credentialing process again when moving from one practice to another within the same state.

    Just take a look at Texas. A credential verification organization has been launched through the collaboration of Texas Medical Association and 19 Medicaid health insurance plans. The organization’s goal is to reduce paperwork for Texas physicians.

    Amanda Hudgens, director of special projects for The Texas Credentialing Alliance (TAHP), stated:

    "We want to simplify the credentialing process for physicians here in Texas and we're focusing on Medicaid providers because we understand they have a lot of paperwork burdens and administrative requirements to become a Medicaid provider."

    Thus, it is important for the one handling your physician credentialing to know all about these varying state regulations.


    The physician credentialing process remains a tedious process if you do not have all the information you need up front. Following the above recommendations will help speed up this process while eliminating inefficiencies.

    Subscribe to our blog for more tips related to medical billing or call us toll-free at (855) 376-7631 for your queries and concerns.

    About ClaimCare

    ClaimCare helps new medical practices and existing organizations with their physician credentialing process. They even assist in training your front desk office staff for a more efficient medical billing process. Learn more.

    Tags: medical billing resources, credentialing, medical credentialing

    5 Factors to Consider When Choosing a Medical Billing Company

    Posted by Carl Mays on Wed, Sep 04, 2019 @ 10:00 AM

    5 Factors to Consider When Choosing a Medical Billing Company_On December 15, 2015, Jason Adam Townsend, owner of a medical billing company, was indicted on healthcare fraud and aggravated identity theft charges by the Charlotte Grand Jury.

    Don't fall victim to these fraudulent medical billing companies. Know how you can select a reliable medical billing company for your medical billing needs.

    When looking for a medical billing company, it is important to consider the following factors:

    1. Service Level of the Medical Billing Provider

    What are the services provided by your medical billing company? Does this include:

    • Pursuing denied claims
    • Billing follow-up
    • Complying with industry regulations
    • Reporting and analysis

    Ensure you discuss these matters with the company before signing up for any of their packages. Doing so will confirm if they are the right service provider for you.

    2. Years of Experience in the Industry

    How long has the medical billing service provider been in the industry? On what medical specialties do they focus?

    These are important questions to consider when choosing a medical billing service provider because it shows if they are knowledgeable in the following areas:

    • Current medical coding system and medical terminology
    • Insurance claims and billing, which includes the appeals and denial process, as well as fraud and abuse detection
    • Information and web technology
    • Reimbursement practices

    3. Knowledge with the Use of Technology

    One of the aims of medical billing is to accomplish more tasks with less time. This is done through the use of sophisticated billing software. But, it does not mean having to work on an entirely new system altogether.

    While most medical billing companies have their own billing system, very few have the capacity to work with the existing system used by an organization. Thus, you are forced to migrate your data into their own. However, this makes the transition process longer and more complicated.

    Rather than migrate your data into a new one, you may prefer a medical billing company  like ClaimCare that can work in your current billing system. In this manner, you don't have to worry about your data being transferred into a new system.

    Thus, it is important to ask them the following questions:

    • Are they willing to work in your current system?
    • How knowledgeable are they with other billing systems?
    • How long will it take to integrate with your billing system?

    4. Security and Compliance

    According to the National Healthcare Anti-Fraud Association NHAA, approximately tens of billions of dollars are lost to health care fraud. This makes it one of the most challenging problems among medical providers.

    Avoid being a victim. Carefully select your medical billing company by inquiring if they perform one or more of the following safety precautions:

    • Annual background checks on their employees
    • Monthly annual checks with the OIG for excluded employees
    • Anonymous methods on how to report employee violations
    • Health Insurance Portability and Accountability Act (HIPAA) training
    • Dedicated compliance officer to ensure your data remains protected

    This will help you assess how much these medical billing companies value the confidentiality of all your records.

    5. Medical Billing Service Efficiency

    Check the performance of the medical billing companies you’re considering. Identify how much of the denied claims and fee collection they are able to deliver by asking for the following data:

    • How many of their current clients match your specialization?
    • How many claims do they process each year?

    It is also helpful to know the following information:

    • Percentage of reduced payment delays
    • Increased revenues they deliver to their existing clients
    • Average number of days in A/R by specialty percentage

    Utilize all of this information when choosing a medical billing company. Remain updated with the current medical billing trends and issues. Subscribe to our blog or call us at (855) 376-7631 for any of your medical billing concerns.

    About Claimcare

    ClaimCare has more than 25 years of experience in medical billing. It has a proven track record of increased customer collection reaching all the way up to 25% (the average increase is approximately 5%) and days in AR under 40 for your collectibles.

    Tags: medical billing, medical billing companies, medical billing services

    5 Reasons Your Medical Claims Are Being Denied

    Posted by Carl Mays on Tue, Sep 03, 2019 @ 10:00 AM

    5 Reasons Your Medical Claims Are Being DeniedSome of the crucial elements in the medical claims process happen during the medical coding and medical billing procedures.

    This article discusses how these two procedures are essential in filing medical claims and why your medical claims are being denied.

    How Medical Coding and Medical Billing Influence Medical Claims Approval

    Medical coding is the process of accurately encoding written documents (e.g., a medical prescription or diagnosis) made by medical experts into a numeric or alphanumeric one. On the other hand, medical billing is the process of assigning a corresponding bill for the insurance or healthcare provider.

    Any incorrect or incomplete coding and billing can result in a denied claim for the following reasons:

    1. The coded information lacks detail or is not clearly rendered by the coder

    There are codes for specific medical terms. It is important for the coder not to overlook even the tiniest bit of information contained therein. The code must be complete. If the coder neglects to input one number or includes an irrelevant one, the code is invalid.

    For example, k35 is acute appendicitis while k35.80 is an unspecified acute appendicitis. Failing to indicate the right type of appendicitis of the patient may be the cause for a denial. Thus, it is important that medical coders and billers be very knowledgeable about these codes.

    2. Mistakes due to outdated coding

    The coder must have an up-to-date book of codes. Documents coded using an outdated set of codes will only lead to an inaccurate output. The coder must be well informed regarding any changes in the coding system.

    3. The claim forwarded to the insurance company is missing relevant information

    Insurance companies are very meticulous. They review all the information required in the claim forms. Any missing information such as date of diagnosis, date of the accident, and any other relevant dates may be the reason for a claim denial. Thus, you should carefully review and ensure all the required information is properly incorporated in the claim forms.

    4. Delayed filing of the claim

    Submission of claims must be made within twelve months from the start date for Medicare. The start date can either be the date the medical service was performed or the date written on the “from” part of the claim form. The claimant may not be granted reimbursement if the filing is not made in a timely manner.

    5. The patient’s personal information is incorrect

    Your medical claims may also be denied if the personal information input into the system is erroneous. Name, age, sex, and other personal details of the patient must be correct.

    Other relevant information such as the insurance company where the reimbursement is requested from and the policy number should also be valid. If the patient is not the insured himself/herself, be sure to state the relationship between the insured and the patient for the claim to be considered. Furthermore, the procedure performed on the patient must correspond correctly to the coded documentation prepared by the coder.

    Are you interested in learning more medical billing tips? Subscribe to our blog to remain posted. You may contact us online for any of your medical billing problems and concerns.

    About ClaimCare

    ClaimCare has years of industry experience in delivering high quality and affordable medical billing services in the U.S. We assist in collecting the maximum revenue for your practice while helping alleviate the medical billing costs and hassle for your organization.

    Tags: medical billing, medical billing services, Medical Reimbursement

    How Much Is In-house Medical Billing Really Costing You?

    Posted by Carl Mays on Wed, Aug 21, 2019 @ 02:03 PM

    How Much Is In-house Medical Billing Really Costing You_Is your in-house medical billing costing more than you can handle? How is this compromising your organization's efficiency?

    Learn how much you are actually spending on your in-house medical billing and how outsourcing it to a third party provider may be a more efficient and better cost-saving solution for you.

    Read on to know the details shared by The Physician's News Digest about medical billing costs in the US.

    The Cost of In-house vs an Outsourced Medical Billing

    Many practices believe that outsourcing their medical billing is more expensive. However, the analysis created by the Physicians News Digest shows it otherwise.

    And, the information supplied by The Physician's News Digest is based on an “average” medical billing company. ‘The Medical Billing Buying Guide’ gives ClaimCare, with our 100% USA-based staff, an A+ rating.

    Hypothetical Facts of the Practice Involved in the Physicians News Digest Analysis

    The following information was considered when creating the analysis of in-house medical billing costs:

    • 3 primary care physicians
    • 2 medical billing specialists
    • 80 insurance claims filed a day (̴20,000 per year)
    • $125 is the average billed amount per claim

    Employee Costs

    A practice with the above-mentioned activity needs two medical billing staff with an average of $40k salary to perform these processes. Thus, the practice is spending approximately $101,000 on them, including their taxes and benefits.

    With outsourced medical billing, there’s no need to think about the medical billing staff related expenditure. However, you would need to consider about five hours of time each week for managing tasks associated with billing at a rate of $15 per hour, which is equivalent to around $4,000 in administrative costs annually.

    Technology Costs

    This includes the following costs:

    • Electronic Health Record (EHR) system
    • Practice Management (PM) software
    • Hardware ($500)
    • Maintenance

    On average, the cost per doctor for the practice management software alone may reach approximately $200 per month. Thus, if the organization has three primary care doctors, it would mean an annual cost of approximately $7000. This doesn't include the upfront costs associated with software purchase and installation. Along with the computer hardware costs of $500, the annual total cost would be around $7500.

    With outsourced medical billing, you may only need to spend for a printer or the workstation that is required to communicate with the medical billing service provider.

    Training Costs

    Keeping your medical billing team updated with the latest coding and billing changes is a challenging task. On average, practices spend $2,000 on training alone. However, with a medical billing third-party provider, there’s no need to worry about this. It is their responsibility to keep all of their medical billing specialists knowledgeable with the latest coding changes. This ensures you always have accurate coding for all your billing services.

    Direct Claim Processing Costs

    The clearing house fees a provider needs to pay for submitting 20,000 claims is at $300 per month ($100 per physician) or $3,600 in a year. When outsourced, the fee is normally based on the percentage of the amount collected, which is normally at 7%.

    This is higher compared to the clearing house fees doctors have to pay. However, given the percentage of billing collected through a medical billing provider, this amount will immediately outweigh its costs.

    Billing Percentage Collected In-House vs Outsourced

    Amidst the higher direct claim processing costs of third-party medical billers, it delivers an increased 10% billing collection to your practice compared to an in-house medical billing team.

    Does this mean it is the right choice for your organization?

    There are many factors for you to consider such as:

    • Billing efficiency of your practice
    • Staff turnover and their technical skills
    • Years of experience in the industry

    If you are a new provider and experiencing high staff turnover with poor technical skills, then it’s better to choose a third-party provider to help you with your medical billing.

    Need help deciding? Call us at (855) 376-7631 or subscribe to our blog to learn more.

    About ClaimCare

    ClaimCare has over 80 years of medical billing experience. We serve virtually all specialties and help improve their billing collection. Learn more about our services. Most of our clients have experienced a 15 to 25% increase in collections and have days in AR under 40. Read more about us as reported by ‘Healthcare Tech Outlook.

    Tags: medical billing, medical billing services

    4 Common Pitfalls and Issues of Medical Credentialing

    Posted by Carl Mays on Mon, Aug 19, 2019 @ 02:00 PM

    4 Common Pitfalls and Issues of Medical CredentialingBeckers Hospital Review has revealed that just a month in delay on an average primary care physician's medical credentialing can cost your practice $30,000. This could even be higher for specialists who handle orthopedics and cardiothoracic surgery.

    Avoid this loss from happening to your organization. Learn the common issues associated with medical credentialing and how to solve them.

    1. Lack of Organization and Bad Workflow

    An efficient workflow will help you avoid medical credentialing problems and delays. Create a workflow to avoid lost money in handling appeals and reimbursements.

    Hire an office coordinator who will be:

    • In charge of your physician’s documentation process
    • Send reminder texts and emails for documents that are not yet submitted
    • Neatly compile these credentialing documents for easy retrieval

    This will help lessen human error in your workflow. Thus, avoiding the need for a re-credentialing process, which will only lead to a longer medical credentialing process.

    2. Lack of Timing and Physician Start Dates

    It’s good to be optimistic, but with medical credentialing it is best not to put things at a minimum, especially with estimating the time needed for the approval of your physician credentialing request.

    Gather all the needed credentialing paperwork on the day the employment offer is given. As needed, extend the start date of your new physician to a maximum to ensure you have properly reviewed and verified all of his or her credentials before joining your organization.

    3. Private Background Checks and Maintaining Updated Contact Information

    Medical credentialing is never easy. Payers will certainly use anything that can deny the payment claim. Therefore, it is important for your organization to diligently perform a private background check on your physician.

    Verify the validity of all the forwarded documents including:

    • License
    • Training
    • Employment history

    Most importantly, ensure the submitted contact information is up to date. The medical credentialing process may take a while, approximately 6 weeks to 3 months. Thus, it is important to know how you can contact them if any additional documents are needed by the payer.

    4. Adhering to All the Needed State Requirements

    Be reminded that states vary with their needed medical credentialing requirements. Additional credentialing requirements may still be necessary even if the physician has successfully been credentialed in another state. Therefore, it is better to check on reciprocity agreements with the payer organization and the state before agreeing to immediately accept the physician into your organization.

    Improve your organization's cash flow while providing quality healthcare to your patients. Do not let obscure state laws cause your office to lose productivity. Understand the laws of your state to make your medical credentialing process faster and easier.

    Do you have more questions about medical credentialing? Subscribe to our medical billing blog or complete our online form for any of your queries and concerns.

    About ClaimCare

    ClaimCare is one of the largest medical billing and medical credentialing providers in the United States. Its entire medical credentialing staff are thoroughly screened, well trained, and provided with the best tools and proper incentives to ensure you are given the best services. For more information about the services we deliver, phone (855) 376-7631.

    Tags: credentialing, medical credentialing

    Impact of Proposed 2019 Medicare to Medical Billing of Ambulatory Surgical Center Services

    Posted by Carl Mays on Thu, Aug 15, 2019 @ 02:00 PM

    Impact of the Proposed 2019 Medicare to the Medical Billing of Ambulatory Surgical Center ServicesLast July, the Centers for Medicare and Medicaid Services (CMS) released a proposed payment rule for the Ambulatory Surgery Center Association (ASCA) and Hospital Outpatient Departments (HOPDs) for 2019. These updates address several long-requested ASCA priorities, which include the following:

    • Threshold for device intensive surgeries and clinic cost visits
    • ASC covered procedures performed in ASC setting
    • Quality Reporting Program

    This article discusses how these points are addressed and the impact on your physician billing and ASC services.

    3 Major Changes for ASC Services Based on Proposed 2019 CMS Payment Rule:

    The changes to the CMS Payment Rule aim to deliver these ASC physician billing advantages:

    1. Lower threshold for device intensive surgeries and clinic cost visits.

    The ASC has long been requesting a lower threshold compared to the current 40 percent applied on its standard OPPS APC rate-setting methodology. Through the Proposed 2019 Medicare Changes, this can now become a reality.

    Under the proposed change, the threshold will now be reduced to 30 percent, thus allowing high-cost devices to be better recognized in ASC settings. Moreover, clinic visit costs would also be reduced from approximately $116 with a copayment of $23 to just $46 with a copayment of only $9. This means an estimated savings of $14 for each off-campus department visit of patients and a $760 million savings for Medicare in 2019.

    2. Expanded ASC Covered Procedures List (CPL).

    Part of the proposed 2019 changes entails the inclusion of "surgery like" procedures that are outside the current CPT surgical range (10000 - 69999) to the ASC CPL. However, these surgeries would be limited to the following conditions:

    • Accepted surgical procedures that are expected NOT to pose any significant risk to the safety of the beneficiary (patient)
    • Does NOT require an overnight stay when performed in an ASC
    • Separately paid under the OPPS

    If implemented, this would lead to a 2% increase rate for ASC, which is based on the combined 2.8% inflation update reported by the hospital market basket and the 0.8% mandated reduction by the ACA. However, it should be noted that this 2% increase will be code-specific, thus it will not be applied to all ASC procedures.

    3. Easier ASC Quality Reporting Program.

    Under the proposed 2019 Medicare, eight measures required by the ASC Quality Reporting (ASCQR) Program for their CY 2020 and CY 2021 payment determinations will be removed. This includes the following:

    • Influenza Vaccination Coverage Among Healthcare Personnel (CY 2020: ASC-8)
    • Patient Burn (CY 2021: ASC -1)
    • Patient Fall (CY 2021: ASC -2)
    • Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant (CY 2021: ASC -3)
    • All Cause Hospital Transfer/Admission (CY 2021: ASC-4)
    • Endoscopy/Polyp Surveillance Follow-up Interval for Normal Colonoscopy in Average Risk Patients (CY 2021: ASC-9)
    • Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps (CY 2021: ASC-10)
    • Avoidance of Inappropriate Use; and voluntary measure Cataracts - Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery (CY 2021: ASC-11)

    This is because ASC's have demonstrated an outstanding performance in preventing serious adverse events. Thus, CMS has found it unnecessary to collect these above-mentioned data measures from them.

    Conclusion: Who would benefit from these changes?

    Ultimately, these proposed policy changes aim to create a better patient-centered healthcare system by providing greater:

    • Price transparency
    • Interoperability
    • Significant burden reduction

    This results in several benefits not only to the patients but also for both ASCs and hospitals. Patients are given more health care options at a minimal cost while ASCs and hospitals can operate with better flexibility.

    Would you like more updates about the Proposed 2019 Medicare and its impact on your physician billing? Subscribe to our blog to remain posted or call us toll-free at (855) 376-7631 today.

    About ClaimCare

    ClaimCare is composed of skilled and knowledgeable medical providers, practice managers, certified coders, experienced business professionals, and engineers. This is to guarantee you receive effective and efficient team physician billing services all year round.

    Tags: medical billing, medical billing services

    5 Solutions to Common Medical Billing Errors

    Posted by Carl Mays on Thu, Jul 18, 2019 @ 02:01 PM

    5 Solutions to Your Common Medical Billing ErrorsDenial of claim is defined in the Health Insurance Glossary as “the refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.”

    This is one of the most pressing problems the healthcare industry is facing today, resulting in a reported loss of net patient revenue ranging from 1 to 5% for your practice, or around two to three million dollars yearly for an average 300-bed hospital.

    Although these denials can be appealed and reworked, physician practices spend approximately $25 cost per claim just for this to be completed. Sadly, the success rates for these appealed claims vary from 55% to 98% depending on the capability of a practice’s medical denial management team.

    A bird’s-eye view of just how much money can be lost by denied claims is posted in the chart below, supplied by the American Association of Family Physicians (AAFP):

    Screenshot 2019-07-18 20.06.49

    How to Fix Common Medical Billing Errors for Increased Revenue

    You can reduce the rate of your medical billing denials with these following recommendations:

    1. Complete all the necessary fields of your medical claim.

    61% of initial medical billing denials and 42% of denial write-offs are due to submitting a medical claim with missing or incorrect demographic information and incorrect plan code. Thus, it is important for your staff to perform due diligence when submitting your claims. This means verifying that all the information needed in the form is filled out properly.

    Do this faster and more efficiently with a scrubber that can check the coding, bundling, and procedure information on your claim prior to submitting it to the payer.

    2. Never resubmit claims on the same date.

    Resubmitting claims on the same date to the same provider for the same beneficiary, even if all entries are complete, is one of the biggest reasons for a Medicare Part B claim denial. Avoid this by encouraging your staff to double-check if a claim has already been submitted before filing another.

    Motivate them to practice this protocol by choosing software with a user-friendly interface. This makes it easier for them to track and check the status of your claims.

    3. Ensure your patients' insurance coverage information is updated.

    Some medical billing denials are a result of your staff's failure to check the details of a patient's insurance eligibility. Thus, you end up filing for a claim that is not covered by the payer.

    Regularly update a patient’s insurance eligibility, as well as his or her basic profile information to ensure you have the most updated information.

    4. Use an alert system to ensure all claims are filed on time.

    There is a limit to the number of days a medical claim can be submitted to a payer. Know the grace period for this, which includes the time you will take to rework any rejections.

    As needed, incorporate into your workflow an alert system that will notify your staff of any medical claim that is approaching the time limit.

    5. Choose the right billing codes.

    Some claims are considered reviewed but denied or reduced by the payer due to an incorrect choice of billing codes, which could either be:

    • Upcoding (assigning a bill to a more expensive medical procedure)
    • Undercoding (failure to include the services you've performed)
    • Insufficient code specificity

    The best solution for this is to have a comprehensive patient record. This includes the laterality, severity, and accompanying conditions of the service provided. This is most helpful to your medical billing staff when assigning the proper codes to it.

    About ClaimCare

    ClaimCare offers a complete medical billing solution for your practice. This includes an EMR, Instant Payment Program, an upfront insurance verification, and a patient collection tool to help improve your practice's revenue. Call us toll-free at (855) 376-7631 or Contact ClaimCare to see how we can improve your profits so you can focus on medicine instead of medical billing.

    Tags: medical billing, medical billing services, improving medical billing

    There Is A Significant Difference Between General Billing & Medical Billing

    Posted by Carl Mays on Tue, Jul 02, 2019 @ 11:00 AM

    Final-puzzle-piece (003)We recently discovered that a new client had just hired an office worker who had a good knowledge of general billing but no experience whatsoever with medical billing. This posed a problem that we solved by meeting with the office worker and explaining some medical billing specifics.

    Following the meeting, we sent her links to six of our blogs to help guide her in comprehending more fully the medical billing process. These links will continue to help her handle more smoothly the front-end billing procedures and assist us in handling the back-end billing operations.

    Since this is not the first time we have encountered such a situation in our 30-year history, we think it is a good idea to share these six links with all of our current clients and potential clients.


    Link 1. Medical Billing Allowables: Why Charge More Than You Expect To Collect?

    In most businesses, if you bill $100 you expect to collect $100. In the healthcare business, a bill for $100 is often sent out with the expectation that only $50, $30 or even less will be collected. Why? This article answers the question and delves into (1) Revenue Enhancement (2) Comparability and (3) Compliance.

    Link 2. Medical Billing Allowables: How To Set A Practice’s Fee Schedules

    This article focuses on setting the overall fee schedule for your practice once you know your allowables, emphasizing: (1) Be consistent (2) Don’t leave money uncollected and (3) Don’t scare away patients. This has been ClaimCare’s highest-viewed article overall.

    Link 3. Medical Billing Allowables: How They Affect EOBs and Medical Billing Reports

    This article focuses on how your allowables and fee schedules shape the EOBs and the reports you will see every day, emphasizing: (1) The main impact you will see on your EOBs is from contractual adjustments and (2) You will see two main impacts on your reports due to the interaction of your fee schedules and your allowables.

    Link 4. Medical Billing Allowables: Understanding Your AR With Medical Billing Yields

    This article deals with how to use the knowledge gained through the first three links to understand better the true value of a practice’s AR. Understanding the concept of “yield” is the key behind understanding the value of a practice’s AR.

    Link 5. Medical Billing Allowables: Predicting Expected Medical Billing Collections

    After having read and absorbed the previous four articles, you are ready to learn how to predict your practice’s month-to-month cash flow. In its simplest form, predicting collections can be done by taking your practice’s average charges per month over the last year and multiplying by your weighted average practice yield. However, in this article you will also gain insight into how to deal with month-to-month variations to get a better handle on your cash flow situation.

    Link 6. Addendum: Allowables and Medical Billing Yields – A Few Additional Thoughts

    The previous article in the series of five outlined why yields are important and how to calculate them. This article follows up with seven tactical points concerning medical billing yields. Yields are a critical component of medical billing and practice management. These seven tactical points should help you become a “power user” when it comes to medical billing yields.

    To receive ongoing information regarding medical billing and to view previously-posted articles: Subscribe to our blog. To learn more about what ClaimCare can do for you, visit ClaimCare – The Medical Billing Professionals, or you may phone us at (855) 376-7631.

    Our mission statement: “To collect the maximum revenue for your practice as fast as possible while helping to alleviate costs and hassle for your organization.”

    About ClaimCare

    Healthcare Tech Outlook named ClaimCare as one of the nation’s “Top 10 Medical Billing Companies” in 2018. This honor follows previous such honors, including being ranked in the “Top 5” by the online magazine, Money & Business. We have a proven track record of increasing client collections by 10 to 20 percent.

    Tags: medical billing services, medical billing resources

    Subscribe by Email

    Most Popular

    Medical Billing Blog Requests

    If you have  specific topic or question you would like to see covered in this blog then please post the question on the Medical Billing Question & Answer Forum.

    If you have a question about ClaimCare's Medical Billing Services please utilize the form below.

    Contact Us