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    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.


    Insurance Payers Moving at Snail-Like Pace

    Posted by Carl Mays, ClaimCare President/CEO on Thu, Jul 16, 2020 @ 03:45 PM

    snail-3901655__340We 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.

    About ClaimCare ®                        

    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 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.



    Tags: 2010 medical billing changes, medical billing compensation, Medicaid billing, medical billing coding, Insurance Payers

    Medical Billing Update: Hold Medicare Claims or Submit Them?

    Posted by ClaimCare Resources on Tue, Jun 15, 2010 @ 11:24 PM

    medical billing medicareClaimCare, Inc - June 15, 2010 - According to various media reports from Washington, action will come too late regarding the June 6 Senate announcement that it is ready to initiate a 19-month Medicare "doc fix." This means cash-flow problems will affect doctors across the country. Senator Charles Schumer (D-N.Y.) said at a press conference that the Senate is expected to have 60 votes to pass the bill "early next week (week of June 14)." But even if the votes come then, more than likely it will take several days for the bill to be passed by the House and signed into law by the President.

    On Monday, June 14th Medicare responded to this continued delay by Congress by deciding that it will extend its freeze on processing claims with June dates of service until Friday, June 18th. It is possible that Congress will reverse the massive Medicare fee reduction by that date. Given, however, the time line outlined by Senator Schumer, it is unlikely the fix will be completed by that time.

    So, on Monday, June 21st, Medicare may well begin processing June 2010 claims using the 21.3% fee reduction that went into effect on June 1. However, it appears highly likely that within two weeks Congress will retroactively reverse the fee cut. This will result in Medicare claims being reprocessed, causing new "make-up payment" problems for providers. It is a situation that leaves providers to ask some important questions - and to make some important medical billing decisions.  

    Question/Decision #1:  Should your medical billing department continue submitting your Medicare claims as usual - or should you hold them until Congress eliminates the 21.3% fee reduction?

    If you submit your claims as usual, then you will receive payments as usual - but at the reduced fee rate. When Congress does eliminate the fee reduction, you will have a lot of work to do when Medicare reprocesses your claims. This work includes auditing to ensure Medicare has indeed made all of the make-up payments they should. It also includes responding to patients' questions and concerns about receiving two Explanation of Benefits (EOBs) from Medicare regarding their charges. The situation will be exacerbated when Medicare automatically crosses these lower-paid claims to secondary insurance payers. EOBs and payments involving secondary (and possibly tertiary) insurance payers will cause further confusion and complications for your office - and  for your patients.

    If you hold your Medicare patient claims and then submit them after Congress passes the "doc fix" bill, you will not get hit with the 21.3% cut - but you will get paid later than usual. You also will have a much simpler time in terms of ensuring all payments are correct from both Medicare and secondary payers. Also, patients will receive only a single EOB for the dates of service during this "waiting" time period.

    Question/Decision #2:  Should you collect co-insurance from Medicare patients under the fee schedule that was in place prior to June 1, 2010 - or under the significantly reduced fee schedule?

    If you collect patients' 20% Medicare co-insurance under the reduced fee schedule and the reduction is reversed by Congress, then under Medicare rules you will need to bill patients for any extra amount they owe over $5.00. (You are not forced to try and collect balances that will cost more to pursue than will be yielded in revenue). This will lead to additional expense and patient confusion.

    On the other hand, if you collect co-insurance amounts in accordance with the pre-June 1 fee schedule and Congress does not reverse the fee reduction, then you will need to reimburse patients any overpayments greater than $5.00. (The same financially reasonable principle applies to patient refunds.) Since it is unlikely that the fee reduction will stand, this is an unlikely outcome.

    Question/Decision #3:  Most likely, you have already filed some June 2010 Medicare patient claims. These will start being processed on Tuesday and will generate many of the issues mentioned above. (The decisions you make now regard being able to minimize the complications rather than being able to avoid them completely.)  These already-filed claims force you to ask and decide: Should you bill patients and secondary insurance payers for the June 1 to June 14 dates of service you submitted (and for which Medicare will begin receiving payment over the coming days) or should you wait for these claims to be reprocessed and paid correctly after Congress reverses the 21.3% Medicare fee cut?

    The pros and cons outlined for the questions/decisions in #1 and #2 also apply to #3. If you proceed with billing patients (and secondary insurances that do not automatically cross over), you will have confused patients who receive an initial statement from you and then receive a second statement from you for additional money after Congress retroactively reverses the fee cut.   

    On the other hand, not billing patients and secondary insurances until after Congress acts will delay your collections - but will lead to much less patient and office confusion.

    My Recommendation:  Every practice must make its own decision about these issues, but a decision must indeed be made. If you can handle the temporary cash flow reduction, then my recommendation is:

    1. Hold your claims until Congress retroactively reverses the Medicare fee cut;
    2. Collect patient co-insurance under the pre-June 2010 fee schedule;
    3. Do not bill patients or secondary insurance for the June 1, 2010 to June 18, 2010 dates of service for which you will start receiving payments over the coming days. Instead, bill the patients and secondary insurances after these dates of service are reprocessed when Congress reverses the Medicare fee cut.

    This approach will minimize confusion in the practice and among your patients. It will also minimize the chance you are underpaid for your claims.


    Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

    Tags: general medical billing questions, 2010 medical billing changes, medical billing, medical billing resources

    Medical Billing Update: July 6 PECOS catastrophe fast approaching

    Posted by Carl Mays on Fri, Jun 11, 2010 @ 06:44 PM

    medical billing pecosUntil recently physicians believed that they had until January 3, 2011 to comply with Medicare's PECOS enrollment requirement. This is no longer the case. In May Medicare announced that a new mandate from the health system reform law forced the deadline to be moved up by 6 months. Starting July 6, 2010 if the physicians that refer to your practice are not properly enrolled in the Provider Enrollment Chain and Ownership System (PECOS) then your cashflow will be interrupted. If a claim is submitted to Medicare after July 6th with a referring physician that is not enrolled in PECOS, then Medicare can reject the claim. This means that your practice needs to work with your referring provider base and ensure that your referring providers are enrolled in PECOS. This is a much higher burden than the more typical medical billing situation where a provider only needs to ensure the he or she is enrolled with a payer.

    In order to mitigate any risk to your practice's cashflow you need to:

    • Generate a report of your top referring providers,
    • Call and check the PECOS system to confirm that your practice's key referrers are properly enrolled (you will need basic information about the providers such as name, tax ID or provider ID),
    • Contact any referring providers that are not properly enrolled with PECOS and make certain they know: 1) they are not enrolled with PECOS, 2) why it is critical that they enroll with PECOS, and 3) how to quickly enroll with PECOS (to eliminate any delays on their part in finalizing their enrollment), and
    • Send thank you notes to all of the providers that are enrolled with PECOS (this is a great way of showing them how much you value their referrals).

    With all of the healthcare bills and Medicare cuts taking up mind share and discussion time, it would be easy to miss the critical PECOS medical billing deadline and find that the 21% Medicare fee cut is one of two big reimbursement problems. Take action TODAY to ensure your practice's cashflow.


    Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

    Tags: general medical billing questions, 2010 medical billing changes, credentialing

    The June 1 Medicare Fee Cut - The Medical Billing Dance Continues

    Posted by Carl Mays on Tue, Jun 01, 2010 @ 01:00 PM

    Medicare Fee cutPhysicians continue to see their collections, cashflow and emotions whipped around like a rag doll in the mouth of a rottweiler. Congress failed to act before the June 1, 2010 deadline. Once again physicians are "officially" under a new Medicare fee schedule that has an average reduction of over 21%. In reaction, Medicare will once more hold claims for the first 10 business days of the month (for June dates of service).

    Physicians are being told that this 10 business day hold will have a minimal impact on their collections. This is not accurate, however, since Medicare is not holding the payments for 10 business days; rather they are holding the processing of the claims for 10 business days. It makes sense to hold the processing since if Congress negates the 21% pay cut then Medicare would need to reprocess the claims. This approach means, however, that at the end of the ten business day hold, Medicare will drop the full amount of held claims into the processing hopper and then the normal time line will begin (in other words, do not expect a big Medicare check on June 15th - which is the 11th business day of June). The bottom line is that unless Congress acts swiftly and thus Medicare begins to swiftly process claims, most physicians will see a big dip in their Medicare collections in June (since the payments typically seen in the last two weeks of a month are from dates of service in the first part of the month).

    Here is the full text of the Medicare announcement (from the Trailblazer Website):

    "The Continuing Extension Act of 2010, enacted April 15, 2010, extended the zero percent update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. CMS believes Congress is working to avert the negative update scheduled to take effect June 1, 2010. To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners and other providers of services paid under the MPFS, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of June. This hold will only affect MPFS claims with dates of service on or after June 1, 2010.   This hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.   Be on the alert for more information about the 2010 MPFS update."


    Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

    Tags: general medical billing questions, medical billing operations, medical billing education, 2010 medical billing changes, medical billing

    Medical billing collections will suffer no matter what Congress does

    Posted by ClaimCare Resources on Thu, Apr 29, 2010 @ 10:57 PM

    medical billing companiesEveryone in the medical billing field is hopeful that Congress will act to defer (and ultimately eliminate) the proposed 21% fee reduction for Medicare.  Keep in mind, however, that March 2010 collections will likely suffer a delay even if the fee cut is deferred.  The coming months will be a challenging time for medical practices and medical billing companies.

    In January 2010 Medicare had a 2 to 3 week delay in processing claims because they needed to update their system after Congress deferred the 21% Medicare fee reduction.  As of today, Medicare is still catching up in their claims processing (a fact that have not officially acknowledged).  ClaimCare found that as of February 23, 2010, Medicare was still at least a week behind in their typical claim processing time frame.  And this level of a delay happened when Medicare had plenty of advance warning concerning the deferral, so you can imagine what delays could result when they have less advance notice.  In addition to this delay, Medicare had a system problem that resulted in multiple weeks worth of secondary claims not crossing over properly.  This Medicare system problem has compounded the delay in collections.

    There is every reason to expect another delay in Medicare payments in March 2010 if Congress issues a last-minute deferral of the 21% fee reduction.  Based upon past evidence and experience, if Congress does issue a deferment, we anticipate a 2 to 3 week delay in the Medicare claims processing and payments.  Therefore, when thinking about your cash flow for March 2010, you should plan for at least an additional 2 to 3 week delay for Medicare payments.

    If Congress decides to delay the fee reduction for only 30 to 45 days (as they are considering), then this problem will be repeated and exacerbated in April if they pass yet another last-minute deferral.  Practices and medical billing companies need to plan on Medicare collections being less predicable and fairly erratic over the next few months.  As I stated earlier, this is a challenging time to be a medical practice or a medical billing company.


    Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

    Tags: medical billing education, 2010 medical billing changes, medical billing, medical billing companies, medical billing services, medical billing resources

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