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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.


    2012 Cardiology Coding and Billing Changes

    Posted by ClaimCare Resources on Fri, Jan 27, 2012 @ 12:42 PM

    cardiology billingMany significant coding and billing changes have been introduced in 2012 for cardiologists, particularly electrophysiologists (EPs). The ClaimCare Medical Billing Company has created a 30 minute training video to bring cardiologists and cardiology practice staff members up to speed on the key 2012 Cardiology Coding and Billing Changes they need to understand to insure they have no compliance, billing or collection issues as a result of these new rules.

    2012 Cardiology Coding and Billing Changes - Part 1 (13 minutes)

    2012 Cardiology Coding and Billing Changes - Part 2 (15 minutes)


    For more insights concerning cardiology billing, please check out the following collection of articles: Cardiology Billing Articles

    About ClaimCare, Inc.

    ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work its clients' medical billing systems.  For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

    Tags: coding questions, general medical billing questions, medical billing education, payer compliance, cardiology billing, 2012 medical billing changes, medical billing, medical billing resources

    Texas Medical Billing News for Medicaid Coverage Verifications

    Posted by ClaimCare Resources on Mon, Aug 29, 2011 @ 05:19 PM

    Texas Medical BillingIf you accept Texas Medicaid then please note the following Texas medical billing changes that have begun as of August 2011. The Texas Health & Human Services Commission will be sending out new plastic Medicaid Cards to all eligible Medicaid Recipients.  The new plastic card will replace the monthly paper cards (Form 3087) to which you are accustomed. This is being done as part of the initiative to increase providers utilization of Texas Medicaid Web Resources for coverage verification and to cut down on the amount of paper that is sent to Texas Medicaid participants.

    Many practices utilize the paper Medicaid cards to assist them with verification of benefits and to determine eligibility.  Please note, that in conjucntion with the move towards plastic cards, Texas Medicaid is now providing real-time; live eligibility and PCP information through their on-line tool at www.YourTexasBenefitsCard.com.

    ClaimCare Medical Billing highly recommends that each Medicaid patients’ eligibility and PCP be verified with each provider visit.  If you are currently scanning traditional insurance cards into your system or EHR, we encourage you to now scan the Medicaid Plastic Cards for the Medicaid and CHIP patients that you serve.

    Here is the relevant excerpt from the August 2011 Texas Medicaid Bulletin: "This week, HHSC is beginning to mail new plastic Your Texas Benefit Medicaid cards to 3.4 million Texans covered by Medicaid. The new cards will replace the paper Medicaid ID (Form 3087) Medicaid clients receive in the mail each month. Texans with Medicaid coverage should receive their new plastic cards by the end of August. They will also get one last paper Medicaid ID in a separate August mailing. The new plastic card will be the client's everyday Medicaid card and will only be replaced if the client changes health plans or the card is damaged or lost. Medicaid providers can now go to www.YourTexasBenefitscard.com and begin using the site for up-to-date information on a patient's eligibility and other services."


    Copyright 2011 by ClaimCare Inc. The author is Susan Price, Austin Office Manager of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

    Tags: medical billing operations, medical billing education, payer compliance, improving medical billing, medical billing resources, 2011 medical billing changes, Medicaid billing

    Medical Billing Tip: Make Payers Abide by their Settlement Agreements

    Posted by Carl Mays on Mon, Jul 27, 2009 @ 09:51 AM

    medical billing

    A series of successful class action lawsuits have led to positive changes for physicians - in theory. I say in theory because medical billing companies and medical billing departments must be vigilant to make sure that payers are living up to the promises they have made as part of their settlement agreements.

    It is critical that quick action be taken each and every time that a settlement agreement is violated. If you believe that Unicare, Humana or BCBS are in violation of their agreement then you need to file a compliance dispute form. Each company requires a different form - of course - but there is no charge for filing a dispute. These forms can be found on the HMO Settlements Web site in the Compliance Center.

    This dispute process has teeth and physicians have recovered millions of dollars in previously denied and underpaid claims. In addition, they have also saved millions more by avoiding repaying amounts that payers asserted were overpayments.

    An example of the rules by which BCBS has agreed to conduct business will demonstrate how significant the changes have been.  As a result of its settlement BCBS:

    • May not seek overpayment recovery beyond 18 months (six months for insured plans) unless fraud is implicated;
    • Must use a clinically based definition of medical necessity;
    • Must adhere to most CPT coding rules, including payment for evaluation and management codes appended with modifier 25 and payment for add-on codes without reduction for Multiple Procedure Logic;
    • Must pay for codes submitted with 59 modifiers to the extent they follow CPT rules regarding designation of separate procedures,
    • Must provide 90 days advance notice of material adverse changes;
    • May not require physicians to participate in all products,
    • Must disclose their methodology for determining "usual, customary, and reasonable" amounts.
    • Must not utilize global periods for surgical procedures longer than CMS', and
    • May not automatically reduce CPT codes to codes of lesser intensity

    In order for your practice to fully take advantage of these changes it is critical that you put in place processes to spot violations so that you can pursue the remedies that are proven to work (as described earlier). This is a great opportunity to take advantage of a more level playing field between providers and payers- do not let this pass you by. Make sure that the medical billing service or employee responsible for your medical billing is taking full advantage of these opportunities.

    To put this into action you need a systematic process (such as automated reporting) to identify violations by the payers. This process needs to be as automated as possible so that you can catch all violations and not just catch them when they have occurred in volumes o large to miss.

    Next you need a process to easily file disputes if a violation has occurred. Again, this must be automated so that it does not always end up at the bottom of the "to do" list. Finally, you need to have a system to follow the disputes to their conclusion.

    With these elements in place you can be confident that you are taking full advantage of the agreements that have been made by payers. In addition, you will have a new and powerful weapon in your arsenal to maximize the legitimate collections you are owed for the high value services you provide and the hard work that you perform.

    2009 copyright by Carl Mays II and the ClaimCare Medical Billing Company

    Tags: medical billing operations, payer compliance, medical billing, improving medical billing

    You are Losing Thousands to Healthcare Billing Underpayments

    Posted by Carl Mays on Mon, Jun 15, 2009 @ 01:08 PM

    insurace underpaymentsI am taking a brief respite from the previously mentioned outline for the series of posts on allowables and fee schedules to mention a key point about allowables - they are often ignored by insurance companies. If you are not systematically comparing your payments to your contracted allowables you are losing thousands of dollars. Most likely, your revenue is 7% lower than it should be - that is right 7%!

    A recent National Health Insurer Report Card compiled by the American Medical Association measured payment accuracy of seven major payers: Aetna, Anthem BCBS, Cigna, Coventry, Human, United Healthcare and Medicare.

    All of these payers to some degree strayed from contracted payment rate.   The worst offender was United (did not pay contracted rate in 38.4% of cases), followed by Cigna (did not pay contracted rate in 33.8% of cases), Aetna (did not pay contracted rate in 29.2% of cases), Anthem BCBS (did not pay contracted rate in 27.9% of cases), Humana (did not pay contracted rate in 15.8% of cases) and Coventry (did not pay contracted rate in 13.3% of cases).  Even Medicare missed contracted payment rates in almost 2% of cases.

    It is hard to methodically track these underpayments.  From our experience at ClaimCare Medical Billing Services, as we look across multiple clients we will see the exact same CPTs being underpaid by the same amount by the same payer in a given month across all of our clients. The following month we will see the same payer switch to underpaying a different set of CPTs. These under payments are not huge but they add up quickly to big dollars for a medical practice. The combination of switching the codes being underpaid from month-to-month and keeping the underpayment amount "under the radar" can make this difficult for an individual practice to spot. It is also difficult for a billing office to spot if they are not comparing your payments to your contracted rates (and dealing with multiple procedure complexities properly).

    At ClaimCare Medical Billing Services we have found that comparison of payments to allowables can increase a medical practice's collections by 5 to 10 percent.    This of course requires a strong process, powerful reporting technology and the ability to track complex procedures methodically-in the end, it can however add thousands of dollars to your bottom line.

    Copyright 2009 by ClaimCare Inc and the ClaimCare Medical Billing Company

    Tags: medical billing operations, medical billing education, payer compliance, medical allowables, improving medical billing

    Texas Medical Billing Tip of the Day - Use the Clean Claim law

    Posted by www.claimcare.net Admin on Sun, Aug 10, 2008 @ 09:24 AM

    texas medical billingTexas has one of the most helpful and powerful clean claim laws in the United States. The penalties for a clean claim violation can go all the way up to the payer being required to pay billed charges; that's right billed charges. The basic idea of the law is that a payer has to respond to a clean claim within 30 days (45 days if it is not submitted electronically). In order to utilize the clean claim law effectively you must have a tracking system built into your medical billing process that flags:

    1. Which payers are subject to the clean a claim law (not all are),
    2. When a claim was submitted,
    3. When a request for information was received from the payer (if you receive one then it stops the 30 day clock until you respond),
    4. When your office responded to the information request (this starts the 30 day clock again), and
    5. When you received a payment or denial.

    The design and implementation of the system and reporting can challenging, but it will pay huge dividends in terms of the penalties from payers and in the way in which you will make payers take notice of your claims next time. At ClaimCare Medical Billing Services we have used our clean claim tracking system extensively and have seen significant rewards for our clients - especially our Texas Medical Billing clients. We have actually received calls from managers at some of our payers that have assured us they would process our claims quickly and asked if we would please stop submitting complaints.

    If you would like more information on this please fill out ClaimCare's Contact Us page.

    Copyright 2008 by Carl Mays II

    Tags: payer compliance, medical billing, improving medical billing, denial management

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