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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.


    Untangling Knots in Medical Billing Process

    Posted by Carl Mays on Fri, Nov 15, 2019 @ 10:00 AM

    Untangling the Knots of the Medical Billing Process

    Medical billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider.





    This task involves several individuals, including:

    • Office administrators
    • Receptionists
    • Medical billers
    • Medical coders

    It is important for any medical practice to know how the medical billing process works in order to avoid facing several problems related to the process.

    Six Steps Involved in the Medical Billing Process

    Effectively (doing the right thing) and efficiently (doing the thing right) while handling the following steps in the medical billing process is crucial for the success of your revenue cycle.

    Step 1: Patient Check-In

    The medical billing process starts the moment the patient requests an appointment with the physician. From here, the receptionist or front desk officer gathers patient information, which includes the following:

    • Name
    • Address
    • Birthdate
    • Contact number
    • Reason for visit
    • Insurance provider
    • Policy number

    It is important to accurately encode this information into the EHR system. Any wrong data encoded may be a cause for a denied or rejected claim in the future.

    Step 2: Confirming Insurance Eligibility of the Patient

    After recording or updating the initial information, the patient’s insurance coverage should be verified by the office administrator. This includes identifying the list of services covered in the patient’s current insurance policy. The administrator should also be aware of the different billing procedures required by a provider, such as the need for pre-authorization prior to billing.

    Once these things have been clarified, the office administrator needs to inform the patient if he or she needs to pay out of pocket for certain services.

    Step 3: Handling the Patient Check-Out

    All services rendered for the patient must be recorded and placed into the patient’s medical record. This means translating all the diagnoses and medical procedures into medical codes. This is where medical coders enter the picture.

    Medical coders determine the diagnoses of the treatments that have been administered to the patient. This is then translated using the ICD or CPT code and encoded into the patient’s ledger.

    Here, the patient’s bills, including previous balances (if any) and new charges, are input in relation to any payments the patient or patient’s provider may have paid, all of which are printed and given to the patient in the form of a receipt.

    Step 4: Accurately Transmitting the Medical Claim

    Now that the diagnoses and treatment services have been properly coded, it is time for the billers to transmit the medical claim to the insurance provider. However, before this is transmitted, it needs to be reviewed internally. This means adhering to written standards and procedures designed by your organization to reduce erroneous claims and fraudulent activity.

    This ensures all data has been accurately entered electronically into provider’s system through a clearinghouse or directly to the provider, such as Medicaid.

    Step 5: Receiving the Payment

    Once the medical claim is received by the insurer, it is reviewed and evaluated. The insurer determines if the entire or just a portion of the bill should be paid, or if it should be denied. All of this depends on the policy and the contract the patient signed with the insurer.

    Step 6: Billing the Patient

    There are instances wherein the patient needs to pay for the remaining bill not covered by the provider. This is the reason why some insurers and healthcare providers implement a co-payment policy.

    If the patient fails to pay the bill accordingly, it is the responsibility of the healthcare provider to followup with the patient through a collection process. Thus, it is important to explain to the patient upfront about the entire medical billing process.

    Learn more medical billing tips. Subscribe and follow our blog today.


    About ClaimCare

    ClaimCare provides a complete solution for all your medical billing concerns. This includes claim submission and follow-up processing, practice analytics and recommendations, instant payment program, automated insurance verification, and patient checkout tool. Learn more about the services we deliver. Complete our online form to schedule an appointment with us.



    Tags: medical billing, medical billing services, medical billing process

    Why Your Practice May Need a Medical Billing Company

    Posted by Carl Mays on Thu, Nov 07, 2019 @ 02:00 PM

    Why You Need a Medical Billing Company for Your Upcoming Private Practice

    According to a 2019 survey by the Kaiser Family Foundation (KFF), there are 478,463 Primary Care Physicians in the USA – and according to a 2019 survey by Statista, there are currently 525,439 Specialty Physicians. (Click on links to see categories and states.)

    From these lists of physicians, some are succeeding well, others are struggling to break even, and still others are closing their offices. Meanwhile, incoming physicians are aspiring to establish their own practices.

    One of the reasons why some practices have failed or are currently struggling to stay open is the lack of strategic planning. Such practices have failed to realize that establishing a private practice is not an easy endeavor and have not answered the questions that all practices face:

    • What are the different measures you need to consider to ensure your practice will survive for several years prior to becoming soundly established?
    • Can you handle the start-up challenges on your own, or do you need the help of another company?
    • Does help from another company include obtaining the services of a professional medical billing company?

    A current source that deals with the challenges of setting up your own medical practice is found in the online magazine, Business News Daily. The January 10, 2019 article is titled:

    How to Open a Private Medical Practice, Step by Step

    This article emphasizes that at the very least, anyone who intends to set up a medical practice should be prepared for the following:

    • Equipment costs of no less than $100,000
    • A line of credit with a minimum of $100,000
    • Enough operating capital for several months
    • Obtaining a medical practice tax ID
    • Obtaining liability and malpractice insurance
    • Obtaining insurance/payer credentialing
    • Deciding on how to handle medical billing

    Along with the basics of capitalization and the other fundamentals of opening a new medical practice, come important additional needs:

    Choosing your staff

    ClaimCare points to an online blog titled Manage My Practice, which covers descriptions of a dozen or more staff members, but begins with the absolute minimum number of staff required:

    1. Front Desk Officer
    2. Clinical Assistant

    This minimum staff means that the front desk officer should be knowledgeable in many areas, including filing medical billing claims and processing your medical credentials. But what happens if the front desk officer can’t come to work? Who will handle her or his duties for the day or possibly longer, including the medical billing?

    Also, rather than one clinical assistant, it is best to have two who can interchange schedules in case one of them becomes ill or is unavailable for work for some other reason.

    The Manage My Practice Blog also responds to the following questions regarding staff:

    1. Why do some offices need more staff and some need less?
    2. What should you do if you can’t figure out if it’s taking too many people to do the work?

    Returning to the Business News Daily article, other needs covered include:

    Purchasing and installing your equipment

    Eight pieces of equipment, with accompanying software, are detailed in this article and, importantly, the first three mentioned are extremely vital to your revenue cycle:

    1. Electronic Health Record System
    2. Practice Management System
    3. Medical Billing System

    Without someone to utilize these software systems effectively (doing the right thing) and efficiently (doing the thing right), you will experience a waste of time and a financial loss.


    How a medical billing company helps your practice

    A medical billing company has a pool of highly skilled medical billers and coders. These professionals have been trained to use various software systems including the above-mentioned. Thus, by working with a third party medical billing provider you are eliminating the burden of finding or training someone to utilize these systems to reach your optimal advantage. As a result, you can better focus on your core offerings and concentrate on further improving your medical services. This also gives you additional time to think of ways to further expand your patient outreach.


    About ClaimCare

    ClaimCare understands the needs of new medical practices. Thus, it provides services that aid you with credentialing and contracting. As needed, it also helps in training your front desk staff with all of these processes.

    In all medical billing areas, ClaimCare:

    · provides the top service level guarantee in the industry

    · offers best-of-breed technology,

    · is based 100% in the U.S.A.

    · has an air-tight medical billing process

    · provides actionable reporting and broad experience

    · can work on its clients' medical billing systems.

    Healthcare Tech Outlook named ClaimCare as one of the nation’s “Top 10 Medical Billing Companies” in 2019. This honor follows previous such honors, including being ranked in the “Top 5” by the online magazine, Money & Business.

    ClaimCare has a proven track record of increasing client collections by 10 to 20 percent.

    For more information, contact ClaimCare Medical Billing Services at sales@claimcare.net, or phone (855) 376-7631, or visit the ClaimCare Medical Billing Company website.

    Tags: medical billing services, medical billing resources

    New Medicare Card: MBI Transition Ends December 31, 2019

    Posted by Carl Mays on Thu, Oct 24, 2019 @ 10:30 AM


    On October 17, 2019, the Centers for Medicare & Medicaid Services (CMS) sent this reminder:

    New Medicare Card: MBI Transition Ends in Less Than 10 Weeks.

    ClaimCare posted a blog back on September 17, 2018, titled Top Three Impacts of Medicare ID Card Changes on Medical Billing Services. You can review the 2018 post and see that it covers several important points and then goes into some detail regarding:

    1. Eligibility Verification of the New Medicare ID Card

    2. Coordination of Benefits with the New Medicare ID Card

    3. Submission of Medical Claims Using the MBI

    Since the transition period that began April 1, 2018, CMS has posted quite a few notices dealing with clarifications and revisions to the initial announcement.

    Previous CMS announcements in 2019 include the following:

    September 26: New Medicare Card: More Questions about Using the MBI?

    September 19: New Medicare Card: Why Use the MBI?

    August 08: New Medicare Card: Will Your Claims Reject?

    July 25: New Medicare Card: Questions about Using the MBI?

    June 20: New Medicare Card: 75% of Claims Submitted with MBI

    March 28: New Medicare Card and MBI Adoption: How Do You Compare?

    March 06: MBI Look-Up Tool Can Be Used With Medicare Advantage Plans (PDF)

    January 10: New Medicare Card: Transition Period Ends December 31

    If you review these announcements, you will see that the majority of practices and facilities have already made the necessary changes, with many tweaking things along the way. Some, after having claims rejected, are learning more about the process. Others have assisted their patients in making sure they have the new cards and have educated them on why the change in cards became necessary.

    If you still need help with the transition in any way during these final weeks prior to the mandated deadline of January 1, 2020, ClaimCare can provide that help.

    In all medical billing areas, ClaimCare:

    · provides the top service level guarantee in the industry

    · offers best-of-breed technology,

    · is based 100% in the U.S.A.

    · has an air-tight medical billing process

    · provides actionable reporting and broad experience

    · can work on its clients' medical billing systems.

    Healthcare Tech Outlook named ClaimCare as one of the nation’s “Top 10 Medical Billing Companies” in 2019. This honor follows previous such honors, including being ranked in the “Top 5” by the online magazine, Money & Business. ClaimCare has a proven track record of increasing client collections by 10 to 20 percent.

    For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net, by phone at (855) 376-7631 or visit the ClaimCare Medical Billing Company website.

    Tags: medical billing services, 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) 376-7631 to learn more about the services we deliver.

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

    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

    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

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