Per national Correct Coding Initiative (CCI) Chapter 3 guidelines, a procedure with a 90 day global period “is defined as a major surgical procedure.” The 90 day global period actually extends to 92 days, to include one day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of […]

Benefits verification & reports for each new patient and each patient who changes insurance plans… Our Orthopaedic Health Team take care of this by verifying the benefits with the insurance company. We ask about deductible/status, co-pay, coinsurance, # visits allowed, authorization requirements, allowable CPT codes, network status, and any other special condition of the policy. […]

OIG believes that CMS didn’t have the tools to identify medical necessity, several coding errors, and documentation deficiencies-and could have saved nearly 36.7 billion in 2017 by auditing improper payments. As a result, the OIG is directing CMS to: 1. Establish new systems and monitoring to evaluate the appropriateness of claims. 2. Instruct Medicare Administrative […]

When most people hear the phrase, “seamless billing,” they often think of the operations on the back-end of the revenue cycle, after a claim has been submitted.   But seamless billing can only be achieved by best practices that happen before the claim is even generated. The revenue cycle starts with the first phone call […]

Reminder: Don’t balance bill Medicare beneficiaries Under the Qualified Medicare Beneficiary (QMB) program for Medicare beneficiaries, providers can’t charge for cost sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. But federal law allows states to limit provider reimbursement for Medicare cost sharing under certain conditions. Dually eligible individuals may qualify […]

Michigan Home Health Agency Owner Pleads Guilty to Health Care Fraud Charges for Role in $8 Million Medicare Fraud Scheme The owner of a Michigan home health agency pleaded guilty today to fraud charges for his role in a scheme involving approximately $8 million in fraudulent Medicare claims for home health services that were procured […]

Effective 8/13/2018` Change Request (CR) 10619 initiates both Medicare manual changes and operational changes related to the New Medicare Card. Medicare will replace the use of Remittance Advice Remark Code (RARC) MA61, referenced in the Medicare Claims Processing Manual, Chapters 1 and 27, with RARC N382 – missing/incomplete/invalid patient identifier (HICN or MBI). Effective for […]

The rise of Musculoskeletal Disorders (MSDs) is proving to be a dire problem. From older generations to newer ones, MSDs are no longer just threating to the health of our bodies; these common disorders are a threatening our economy—our society—our way of life.  Spanning from minor fractures to the more serious cases such as osteoporosis, […]

Even in the most efficient of offices, claims will still be denied.  The average office will have approximately 5-10% of claims rejected or denied, and the efforts needed to resolve those claims can be a drain on resources.   Follow-up on denied claims is time-consuming.  When questions cannot be answered through the remark coding on […]

We all understand how important it is to protect our patients’ privacy.  In an ideal world, every healthcare provider would have such perfect system in place, they wouldn’t need to worry about HIPAA compliance.  However, the fast-paced medical office can sometimes put specific compliance activities on the back burner, which is a mistake.  Below is […]

Most of New York’s Claims for Federal Reimbursement for Monthly Personal Emergency Response Service Charges Did Not Comply With Medicaid Requirements New York provides Personal Emergency Response Services (PERS) to eligible Medicaid beneficiaries through contracts negotiated between local social services districts (local districts) and PERS providers. Beneficiaries authorized to receive PERS receive electronic communication equipment […]

The Centers for Medicare and Medicaid Services (CMS) rolled out the Targeted Probe and Educate (TPE) programs for the Medicare Administrative Contractors (MAC) to begin identifying targeted providers and sending out round-one reviews by the end of last year. The TPE process is only used with providers that have high denial rates or unusual billing […]

UnitedHealthcare Commercial Product and Sourcing Update for Hyaluronic Acid Product – Durolane® Beginning May 1, 2018, UnitedHealthcare will require that Durolane® be obtained from a designated specialty pharmacy for UnitedHealthcare commercial plan members. This is the same process currently required for Gel-one,® Supartz,® Hyalgan,® Orthovisc,® Gel-Syn,® Gelsyn-3,® Genvisc,® and Hymovis.® These requests also may be […]

New Policy – Advanced Practice Health Care Professional Evaluation and Management Procedures Policy Effective for claims with dates of service on or after Sept. 1, 2017, UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote […]

Starting June 1, 2018, providers in the BlueCare Tennessee and CoverKids networks who supply or service a knee brace that exceeds $200 will need prior authorization. The No Prior Authorization Required list on bluecare.bcst.com will be updated June 1, 2018 to reflect this change. Providers who are out of network will be required to request […]

Member ID Number Prefix Update.. We want you to know about a recent change we made to our Member ID card prefixes. Effective April 15, 2018, we modified them to allow numeric characters in addition to the traditional alpha-only ones. We made this decision to expand the pool of prefixes needed to support the various […]

There’s a lot not to like about the Affordable Care Act (ACA), but it has its advantages for appeals. The Affordable Care Act spells out specific appeals rights for providers, and payers are seeing more appeals that cite compliance with the statute. At 45 CFR § 147.136, the Affordable Care Act statute describes provider rights […]

Seeing timely filing adjustments can be incredibly frustrating, but sometimes they are unavoidable for reasons outside of the office’s control.  What the office can control, however, is making sure that providers are aware of any time constraints involving addendums or outstanding paperwork that is needed to file a claim.