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"Fees" & "Insurance" Articles
Click on the title to see the article summary and a link to the full article.
February 11th, 2021
2021 Medicare Physician Fee Schedule Updates - Do You Really Need to Worry?
January 11th, 2021
Good and Bad News Regarding the 2021 Medicare Physician Fee Schedule
By Wyn Staheli, Director of Research | Published January 11th, 2021
When the proposed Medicare Physician Fee Schedule came out last year, it really got everyone worried. In a time where we are all facing issues related to COVID, this seemed like a really big problem. Professional organizations lobbied and everyone tried to stop the proposed changes, and the 10.2% decrease didn’t happen, but other changes will still be taking place. So how bad is it really and how will it affect your organization?
December 8th, 2020
Final Rule on Communications Technology and 2021 Physicians Fee Schedule
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...
November 5th, 2020
Are You Aware of the 2021 Star Rating System Updates?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 5th, 2020
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:
Quality of ...
September 23rd, 2020
My Location and CBSA is Missing!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 23rd, 2020
We often get questions on missing Core Based Statistical Areas, known as CBSAs. CBSAs are used for pricing and other factors according to the geographical location. If you do not see your CBSA, it is important to note they are not missing - it may not have an assignment, according to ...
August 7th, 2020
Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices
By Wyn Staheli, Director of Research | Published August 7th, 2020
On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.
July 9th, 2020
Payment Adjustment Rules for Multiple Procedures and CCI Edits
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2020
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...
July 1st, 2020
Understanding UCR Inpatient Fees used on DRGs
June 15th, 2020
Outpatient Facility Pricing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2020
Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information based on databases of insurance claims from private-sector health care providers.Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate ...
March 30th, 2020
Spotlight: UCR Fees are Available on DRGs- Check it Out!
By Brittney Murdock, QCC, CMCS, CPC | Published March 30th, 2020
Check out the information page on any DRG! Look up DRGs by going to the list of DRG codes found under the Codes tab at the top of the page, or simply type in the desired DRG by using the search bar on the homepage.
When using the search bar, be sure you have the ...
December 4th, 2019
Preview the PDGM Calculator (HIPPS calculator) for Home Health Today
By Wyn Staheli, Director of Research | Published December 4th, 2019
Find-A-Code's Patient-Driven Groupings Model (PDGM) home health payment calculator (HIPPS Calculator) simplifies payment calculations. See https://www.findacode.com/tools/home-health/ .
December 3rd, 2019
Answering the Question: Does my Insurance Cover Chiropractic Care?
By Wyn Staheli, Director of Research | Published December 3rd, 2019 - Last Review/Update December 4th, 2019
The question "Does my insurance cover chiropractic care" is the ongoing question chiropractic offices have struggled with for years. Unfortunately, when it comes to insurance, coverage often varies between payers — even varying between plans for a single payer so there isn't one easy answer.
November 25th, 2019
New Medicare Home Health Care Payment Grouper — Are You Ready?
By Wyn Staheli, Director of Research | Published November 25th, 2019
In 2020, Medicare will begin using a new Patient-Driven Groupings Model (PDGM) for calculating Medicare payment for home health care services. This is probably the biggest change to affect home health care since 2000.
November 20th, 2019
VA: How UCR Charges are Determined
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 20th, 2019
How does the VA determine charges billed to third party payers for Veterans with private health insurance?
According to the VA. "38 C.F.R 17.101 stipulates the basic methodology by which VA bills third party insurance carriers. In order to generate a charge for medical services, VA establishes reasonable charges for five ...
November 11th, 2019
And Then There Were Fees...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 11th, 2019
Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...
October 21st, 2019
VA- Reasonable Charges Rules, Notices, & Federal Register
August 21st, 2019
So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 21st, 2019
You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from? It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems. One of the ...
August 20th, 2019
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
April 1st, 2019
Spinal Cord Stimulator Used for Chronic Pain
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 1st, 2019
Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes.
ICD-10-CM Diagnosis Codes ...
March 1st, 2019
Understanding NCCI Edits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
January 10th, 2019
Are You Protecting Your Dental Practice From Fraud?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019
With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...
November 28th, 2018
No Good Deed Goes Unpunished
By Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA | Published November 28th, 2018 - Last Review/Update January 21st, 2019
You simply need to read the headlines, posts, and tweets, about providers across the healthcare profession being audited, fined, and some even convicted, to see that the costs of non-compliance are real. We tell ourselves, “It won’t happen to me.” The reality is that it easily could. Your license is your livelihood.
November 26th, 2018
CMT Fees in 2019
By Wyn Staheli, Director of Research | Published November 26th, 2018 - Last Review/Update January 30th, 2019
Now is the time to prepare. There were some minor reductions to the RVUs for CMT codes 90840-90843. Check here to see what those changes are.
November 7th, 2018
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
October 17th, 2018
Wolters Kluwer Drug Pricing
By Find-A-Code | Published October 17th, 2018
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
August 27th, 2018
Pricing for ASC’s and APC’s
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 27th, 2018
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
May 30th, 2018
Routine Waiver of Patient Out of Pocket Expenses
By Linda Walker | Published May 30th, 2018 - Last Review/Update June 4th, 2018
Medical billers often encounter the dilemma of a physician who wants to be the hero to his or her patients and waive their out-of-pocket expenses. Out-of-pocket expenses include a patient's co-payment, coinsurance, deductibles, charges above U&C (Usual and Customary), and even services a plan may not cover in some situations....
March 1st, 2018
New Bipartisian Budget Act of 2018 Provisions
By Wyn Staheli, Director of Research | Published March 1st, 2018
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.
Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...
February 13th, 2018
Payment Rates Increase for Behavioral Health Office Services
By Wyn Staheli, Director of Research | Published February 13th, 2018
Behavioral health providers may see some improvement in payment rates for office-based behavioral health services. This is due to the fact that the overhead expense evaluation portion of the RVU was increased. The following information is from the Federal Register (see References):
We agree with these stakeholders that the site of service ...
February 1st, 2018
Don’t Be Hesitant About Collecting Co-Pays
By | Published February 1st, 2018
If you are hesitant about collecting co-pays, consider that you may be paying interest on credit cards, property mortgages, and business loans. Each dollar that you do not collect in co-pays could have been used to pay down the practice debt. Without question, if you are having difficulty finding ways ...
January 31st, 2018
Adjusting Your Collection Strategies to HDHPs
By Ashley Choate | Published January 31st, 2018 - Last Review/Update March 29th, 2018
High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....
January 25th, 2018
UCR Pricing, What is it?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 25th, 2018
UCR (Usual, Customary, and Reasonable) pricing is a method of generating healthcare pricing based on the average pricing in a particular geographic location. Gathering information on pricing based on what other providers in that area is charging is commonly used for a fee or payment reference, as it gives a basis ...
January 10th, 2018
MIPS - To Participate or Not Participate - That is the Question
By Wyn Staheli, Director of Research | Published January 10th, 2018
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
December 28th, 2017
Anesthesia
By Raquel Shumway | Published December 28th, 2017
Anesthesia services fall into one of the following categories ranging from lowest to greatest:
Local or topical anesthesia (not covered here)
Moderate (conscious) sedation (See “Moderate Sedation” on page xx)
Regional anesthesia
General anesthesia
Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. General anesthesia may only ...
December 26th, 2017
CHIP Reauthorization for 2018
By Jared Staheli | Published December 26th, 2017
The authorization for the Children's Health Insurance Program (CHIP) funding expired at the end of September 2017. The aim of the program is to fund health insurance for children in families who make too much to qualify for Medicaid but cannot afford private insurance. Without reauthorization, 9 million children are ...
December 13th, 2017
Specialty Exceptions — 2018 PE RVU Changes
By Raquel | Published December 13th, 2017
Some specialties are not included in the new PPIS PE/HR RVU changes
November 28th, 2017
Medicare Expands Value Based Plans
By Wyn Staheli, Director of Research | Published November 28th, 2017
In 2015, the CMS Innovation Center announced plans for new value-based Medicare Advantage plans in an effort to reduce healthcare costs while improving quality of care. This five year pilot program began in 2017 with seven states and is expanding to ten states for 2018. Results must have been positive because they ...
November 17th, 2017
Average Wholesale Price (AWP)
By David Berky | Published November 17th, 2017
Clinical Drug Information, LLC Average Wholesale Price (AWP) is intended only to be used by Clinical Drug Information, LLC customers. While many use this information as a price index, the Clinical Drug Information, LLC AWP does not represent an average of wholesale prices from any group of transactions in the ...
November 7th, 2017
Four Final Rules Affecting CMS Payments for 2018
By Wyn Staheli, Director of Research | Published November 7th, 2017
It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
This ...
November 6th, 2017
New Payment Rulings Could Affect You
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
November 6th, 2017
Payment Rulings and Small Provider Practices
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
August 23rd, 2017
Funding Extended for Veterans Choice Program
By Jared Staheli | Published August 23rd, 2017
The Veterans Choice Program, created in 2014, was part of the solution to the extensive waiting times found in the VA system. The program allowed veterans to meet their health care needs from private health care providers. Though the “sunset” of the program was avoided earlier in the year, the ...
August 23rd, 2017
VA Patient-Centered Community Care and Veterans Choice Program: Worth it for Providers?
By Jared Staheli | Published August 23rd, 2017
As the opportunities for providers outside the VA system expand in order to meet demand, you may be interested in offering services to veterans and the VA, if you are not already. With overwhelming bipartisan support, the opportunities are not likely to abate, but are those opportunities worth it for ...
August 15th, 2017
Transparency and Fees
By Christine Taxin | Published August 15th, 2017
More than any other industry, healthcare is almost notorious for its lack of price transparency. While patients generally know how much their copay will be and certainly how much their final bill turns out to be, few hospitals and practices publish the actual costs of their services prior to those ...
August 4th, 2017
Veterans Choice Program
By Wyn Staheli | Published August 4th, 2017
In 2017, President Trump signed into law changes to the Veteran's Choice program, which allows veterans to seek care from a civilian (privately contracted) healthcare provider, closer to home, when obtaining care through the VA has become burdensome to the veteran or requires the veteran to wait too long for an appointment.
June 28th, 2017
Medicare Announces New Cards to Be Issued
By Dr. Mario Fucinari, Author & Member of the Carrier Advisory Committee for Medicare | Published June 28th, 2017 - Last Review/Update February 8th, 2019
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.
May 12th, 2017
When Using Code 99050 (After Hours)
By | Published May 12th, 2017 - Last Review/Update February 8th, 2019
Question: When using code 99050 (after hours), do I just add a amount, example $25.00, to our normal total charges for that patients visit?
February 16th, 2017
Have You Evaluated Your Fees Recently?
By ChiroCode | Published February 16th, 2017 - Last Review/Update March 5th, 2019
Many providers are unsure of where their fee schedule actually came from or when it was last reviewed. As a component of compliance and for other preventive purposes, fee schedules should be evaluated once per year. Read more to help evaluate your fee schedules.
February 15th, 2017
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
By CMS.gov | Published February 15th, 2017
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients.
February 8th, 2017
Medicare Conversion Factor
By Wyn Staheli, Director of Research | Published February 8th, 2017
In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...
February 6th, 2017
Quality Reporting is not Just for CMS
By Wyn Staheli, Director of Research | Published February 6th, 2017
If you thought that quality reporting is just for CMS, you are wrong. Other payers recognize the need to establish quality metrics.
February 6th, 2017
Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published February 6th, 2017 - Last Review/Update February 8th, 2019
We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?
January 16th, 2017
Alternative Payment Models (APMs) and Advanced APMs
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
January 13th, 2017
Whiplash Damages
By ChiroCode | Published January 13th, 2017 - Last Review/Update January 31st, 2019
Whiplash Damages in Rear-end Collisions - The Patient’s Dilemma:
The rear-end collision is a major cause of cervical spine injuries which often require treatment by chiropractors and other health care practitioners. Claims adjusters trivialize soft tissue injuries [it’s “only” a sprain or strain] but whiplash is real and so are the damages that come with it.
December 7th, 2016
Discounts
By Wyn Staheli, Director of Research | Published December 7th, 2016
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...
December 7th, 2016
Insurance Denying Everything as Maintenance
By ChiroCode | Published December 7th, 2016 - Last Review/Update March 4th, 2019
Are you having a difficult time getting reimbursed? Are claims being denied because the insurance classifies everything as maintenance?
November 30th, 2016
When can I Bill for a Consult E/M Code?
By | Published November 30th, 2016 - Last Review/Update March 5th, 2019
Physician referrals -- When can we bill a consult code? If we do not have the referral on our referral pad can we bill the consult code?
November 18th, 2016
It's Time to Evaluate Your Fees!
By ChiroCode | Published November 18th, 2016 - Last Review/Update March 5th, 2019
Why might it be necessary to evaluate your fees?
October 11th, 2016
How to Handle Billing for a Patient With Multiple Plans
By ChiroCode | Published October 11th, 2016 - Last Review/Update March 4th, 2019
In the case of a patient who has multiple plans, which plan is primary and which is secondary?
September 17th, 2016
Consumer Directed Health Plans (CDHP)
By Wyn Staheli, Director of Research | Published September 17th, 2016
Consumer Directed Healthcare Plans (CDHP) were developed as a way to shift the control of healthcare dollars from the insurance companies to the patient (consumer). The goal of these types of plans is to allow the patient to take a more active role in their own health and healthcare decisions ...
September 17th, 2016
Government Healthcare Programs
By Wyn Staheli, Director of Research | Published September 17th, 2016
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
June 27th, 2016
CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)
By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...
June 15th, 2016
Q&A: Do you think insurances will continue to raise deductibles and copay/co-insurance amounts?
By | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Q&A: Do you think insurances will continue to raise deductibles and copay/co-insurance amounts?
May 26th, 2016
Groupon: Is it worth the risk?
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published May 26th, 2016 - Last Review/Update March 5th, 2019
Our team is frequently asked if it is legal for chiropractic offices to offer coupons or Groupons. We’re not allowed, as a profession, to dramatically discount our services, offer free treatments, or provide gifts or free meals for potential patients. Any one of these things can be considered an “inducement.” Practices that improperly induce patients to seek care or services, for example, by providing coupons for care or supplies, may find that they are in violation of the law if they aren’t careful.
So what will that mean to you and your practice? It isn’t pretty.
May 3rd, 2016
Medical History and Health History Forms
By ChiroCode | Published May 3rd, 2016
The Medical History and Health History forms are very important documents for the initial patient visit. Most patients dislike filling out forms when they arrive and sometimes they may not bring all the necessary information with them.
By completing this form before arrival, the patient saves their time as well as ...
May 3rd, 2016
Provider/Patient Dynamic Changes as Result of High Deductible Plans
By Wyn Staheli, Director of Research | Published May 3rd, 2016
High-deductible plans are changing the way patients utilize medical services, therefore, providers must also adapt by adjusting both their communication and billing practices to keep pace with these changes.
April 5th, 2016
Mental Health Parity Information
By Instacode Institute | Published April 5th, 2016 - Last Review/Update January 2nd, 2019
Providers need to understand that even though there are now federal laws, state laws are often different. It is important to ascertain patient coverage before treatment begins. This article contains some federal laws which address mental health services.
March 4th, 2016
What is an 'Other Qualified Healthcare Professional'?
By Wyn Staheli | Published March 4th, 2016
What's the difference between a physician, an other qualified healthcare professional, clinical staff and individual.
January 29th, 2016
What is MIPS?
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
December 11th, 2015
The Benefit of Checking Benefits
By | Published December 11th, 2015
Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure? In many cases outpatient procedures...
September 11th, 2015
Essential Health Benefits (EHBs)
By Wyn Staheli, Director of Research | Published September 11th, 2015 - Last Review/Update February 25th, 2016
Information about the mandated Essential Health Benefits (EHBs). Includes links and other helpful information.
August 19th, 2015
Summary of Adjustments to Fee Schedule Computations (Rev.1931, Issued:03-12-10)
By | Published August 19th, 2015
For services prior to January 1, 1994, B/MACs computed the fee schedule amount for every service. Through 1995, the fee schedule amount is the transition fee schedule amount. For services after 1995, CMS computes and provides the fee schedule amount for every service discussed below. Certain adjustments are made in ...
August 19th, 2015
First Physician Fee Schedule Proposed Rule Since SGR Repeal
By Wyn Staheli, Director of Research | Published August 19th, 2015
Even though the SGR has been repealed, providers still need to be aware of annual fee revisions by CMS. On July 8, 2015, CMS announced their first proposed Medicare Physician Fee Schedule (MFPS) since the SGR repeal. As in years past, there will continue to be reviews of the Relative Value ...
August 10th, 2015
Hardship Discounts
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
What are they and how can I safely create one based on the patient's poverty level?
August 3rd, 2015
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
July 10th, 2015
Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)
By Jared Staheli | Published July 10th, 2015
Carriers shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the carrier record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory ...
July 9th, 2015
Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Under Part B, for services rendered on or after July 1, 1984, clinical laboratory tests performed in a physician’s office, by an independent laboratory, or by a hospital laboratory for its outpatients are reimbursed on the basis of fee schedules. Current exceptions to this rule are CAH laboratory services as ...
July 9th, 2015
Initial Development of Laboratory Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Initially, each carrier established the fee schedules on a carrier-wide basis (not to exceed a statewide basis). If a carrier’s area includes more than one State, the carrier established a separate fee schedule for each State. The carrier determined the fee schedule amount based on prevailing charges for laboratory billings ...
July 9th, 2015
Annual Fee Schedule Updates (Rev. 2106, 01-03-11) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
The CMS adjusts the fee schedule amounts annually to reflect changes in the Consumer Price Index for all urban consumers (CPI-U) (U.S. city average) and the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity, unless alternative updates are specified by legislation. The CMS communicates this ...
July 9th, 2015
Deductible and Coinsurance Application for Laboratory Tests (Rev. 2581, 04-01-13)
By Jared Staheli | Published July 9th, 2015
Neither the annual cash deductible nor the 20 percent coinsurance apply to:
• Clinical laboratory tests performed by a physician, laboratory, or other entity paid on an assigned basis;
• Specimen collection fees; or
• Travel allowance related to laboratory tests (e.g., collecting specimen).
Codes on the physician fee schedule are generally subject to ...
July 9th, 2015
Clotting Factor Furnishing Fee (Rev. 3055, 01-05-15)
By Jared Staheli | Published July 9th, 2015
The Medicare Modernization Act section 303(e)(1) added section 1842(o)(5)(C) of the Social Security Act which requires that, beginning January 1, 2005, a furnishing fee will be paid for items and services associated with clotting factor.
Beginning January 1, 2005, a clotting factor furnishing fee is separately payable to entities that furnish ...
July 9th, 2015
Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06)
By Jared Staheli | Published July 9th, 2015
Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti-cancer chemotherapeutic drugs, and oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen. Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State ...
July 6th, 2015
Coinsurance and Deductible for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.
The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.
As a result of the Affordable Care Act, ...
June 29th, 2015
Deductible and Coinsurance for Prostate Cancer Screening Tests and Procedures (Rev. 1, 10-01-03)
By Jared Staheli | Published June 29th, 2015
The screening PSA test is a lab test to which neither deductible nor coinsurance apply. Both deductible (if unmet) and coinsurance are applicable to screening rectal examinations.
...
June 26th, 2015
Deductible and Coinsurance (Rev. 1, 10-01-03)
By Jared Staheli | Published June 26th, 2015
Neither the Part B deductible nor coinsurance apply for services paid under the laboratory fee schedule. The Part B deductible for screening Pap smear and services paid for under the physician fee schedule is waived effective January 1, 1998. Coinsurance applies.
A. Carrier Action for Submitting Claim to CWF and CWF ...
June 25th, 2015
Waiver of Cost Sharing Requirements of Coinsurance, Copayment and Deductible for Furnished Preventive Services Available in Medicare (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
Section 4104(b)(4) of the ACA, amends section 1833(a)(1) of the Act, by requiring 100 percent payment for the IPPE, AWV and for those preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a grade of A or B for any indication or population and that are ...
June 25th, 2015
Carrier - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, §432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.
The services that may be paid ...
June 25th, 2015
FI - Medicare Part B Services Paid Under Various Fee Schedules for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The legislative change in MMA §630 of 2003, which was effective January 1, 2005, and indefinitely extended by §2902 of the ACA, allows IHS providers to bill for other Medicare Part B services, not covered under §1848 of the Act. In an effort to clarify that these charges are not ...
June 18th, 2015
Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.hhs.gov/providers/pufdownload/default.asp
The DMEPOS fee schedule applies to claims to FIs as follows.
BILL TYPE/ DEFINITION
ORTHOTICS/ PROSTHETICS
DME/ OXYGEN
12X (Hospital inpatient Part B)
Subject to fee schedule
Not covered, therefore, ...
June 18th, 2015
Contractor Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The following instructions apply to all contractors processing DMEPOS claims:
First the 'allowable amount' is determined. This is the lower of the fee schedule amount or the billed charge.
The application of deductible and coinsurance are calculated as follows.
A. Claims to Carriers and DMERC
Any unmet deductible is subtracted from the allowed ...
June 17th, 2015
Calculation and Update of Payment Rates (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Section1834 of the Act requires the use of fee schedules under Medicare Part B for reimbursement of durable medical equipment (DME) and for prosthetic and orthotic devices, beginning January 1 1989. Payment is limited to the lower of the actual charge for the equipment or the fee established.
Beginning with fee ...
June 17th, 2015
Update Frequency (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The DMEPOS fee schedule is updated annually to apply update factors and quarterly to include new codes and correct errors.
The July 2003 update of the DMEPOS fee schedule is located at http://cms.hhs.gov/manuals/pm_trans/AB03071.pdf
The October 2003 quarterly update is located at: http://cms.hhs.gov/manuals/pm_trans/AB03100.pdf
...
June 17th, 2015
Contents of Fee Schedule File (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The fee schedule file provided by CMS contains HCPCS codes and related prices subject to the DMEPOS fee schedules, including application of any update factors and any changes to the national limited payment amounts. The file does not contain fees for drugs that are necessary for the effective use of ...
June 17th, 2015
General Payment Rules (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
DMEPOS are categorized into one of the following payment classes:
• Inexpensive or other routinely purchased DME;
• Items requiring frequent and substantial servicing;
• Certain customized items;
• Other prosthetic and orthotic devices;
• Capped rental items; or
• Oxygen and oxygen equipment.
The CMS determines the category that applies to each HCPSC code and issues ...
June 17th, 2015
Used Equipment (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For payment purposes, used equipment is considered routinely purchased equipment and is any equipment that has been purchased or rented by someone before the current purchase transaction. Used equipment also includes equipment that has been used under circumstances where there has been no commercial transaction (e.g., equipment used for trial ...
June 17th, 2015
Capped Rental Fee Variation by Month of Rental (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For the first three rental months, the capped rental fee schedule is calculated so as to limit the monthly rental to 10 percent of the average of allowed purchase prices on assigned claims for new equipment during a base period, updated to account for inflation. For each of the remaining ...
June 17th, 2015
Payment for Power-Operated Vehicles that May Be Appropriately Used as Wheelchair (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The allowed payment amount for a power-operated vehicle that may be appropriately used as wheelchair, including all medically necessary accessories, is the lowest of the:
• Actual charge for the power-operated vehicle, or
• Fee schedule amount for the power-operated vehicle.
(Rev. 1, 10-01-03)
...
June 17th, 2015
Oxygen and Oxygen Equipment (Rev. 2465, 10-01-12)
By Jared Staheli | Published June 17th, 2015
For oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.
When an inpatient is not entitled to Part A, payment may not be made under ...
June 17th, 2015
Adjustments to Monthly Oxygen Fee (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
If the prescribed amount of oxygen is less than 1 liter per minute, the fee schedule amount for stationary oxygen rental is reduced by 50 percent.
The fee schedule amount for stationary oxygen equipment is increased under the following conditions. If both conditions apply, contractors use the higher of either of ...
April 28th, 2015
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 28th, 2015 - Last Review/Update January 25th, 2017
FACT SHEET
April 24, 2015
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
OVERVIEW: On April 24, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and ...
March 27th, 2015
Will the SGR be Repealed?
By Wyn Staheli, Director of Research | Published March 27th, 2015 - Last Review/Update June 9th, 2016
It appears that the repeal of the Sustainable Growth Rate formula (SGR) could finally be a real possibility. On Thursday, March 26, The U.S. House of Representatives overwhelmingly passed H.R 2, The Medicare Access and CHIP Reauthorization Act which includes both repeal and replace the flawed SGR formula that has ...
February 10th, 2015
MAC Jurisdictions Resources
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
February 4th, 2015
Virtual Cards
By Wyn Staheli | Published February 4th, 2015 - Last Review/Update June 9th, 2016
Sometimes called "disposable," "temporary," or "one-time use" numbers, a virtual credit card number is "like putting a wall" between your transaction and your regular account, says Steve Kenneally, vice president of the American Bankers Association. Although these cards can protect the cardholder from fraud, the use of virtual cards as ...
January 9th, 2015
How Important is Your Fee Schedule?
By | Published January 9th, 2015 - Last Review/Update June 13th, 2016
Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:
• Prompt an audit or some level of claims review
• Cause claims delays
• Increase provider liability in case of an audit or investigation
• Potentially lead to being paid less than the actual value of ...
January 8th, 2015
Discounts by ChiroCode
By ChiroCode | Published January 8th, 2015 - Last Review/Update January 30th, 2017
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing Section F-Fees of the ChiroCode DeskBook for important information on fee schedules and ...
November 21st, 2014
Understanding TOS Discounts and DMPOs
By | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Time-of-Service (TOS) discounts are a common occurrence in chiropractic. What is often assumed is that if insurance isn't involved, there are no rules that apply.
Unfortunately, this is a myth that can become costly to practices and damage provider/patient relationships. So read on to learn the facts about TOS discounting and ...
November 19th, 2014
Getting Ready for 2015
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In effort to aid in the preparation of this year, I have listed some common helpful tips that you might follow in order to best manage your workload ahead.
-Evaluate fees:Â Fee ...
October 29th, 2014
Getting Ready for 2015
By | Published October 29th, 2014 - Last Review/Update January 30th, 2017
Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In effort to aid in the preparation of this year, here are some common helpful tips that you might follow in order to best manage your workload ahead.
-Evaluate fees: Fee schedules ...
October 20th, 2014
PPO Plans
By | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Are PPOs are affecting the value of your practice?
Did you know that taking a 20% PPO write-off on a $200 procedure with a 60% overhead cuts practice profits in half?
By participating in PPO plans, you agree to take a certain discount on fees; however, your fixed overhead costs remain the same ...
October 9th, 2014
Who Has Dental Coverage?
By | Published October 9th, 2014 - Last Review/Update January 27th, 2017
Who has dental benefits?
At year-end 2012, approximately 187 million Americans (2013 NADP/DDPA Joint Dental Benefits Report on Enrollment), or 60 percent of the population, had dental benefits. About 99 percent of dental benefits are provided through an employer or other group programs like AARP. Group coverage also includes public programs like Medicaid, the federal ...
September 25th, 2014
Virtual Credit Cards -A new trend in trying to keep up with E-Health
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Beware of the changes sneaking in as “money streams” in the name of EFT standards. Virtual Credit Cards are being used in provider’s offices as payments from payers; clearinghouses are starting to offer this service as well.
Effective January 1, 2014, health plans were required to offer electronic funds transfer (EFT). ...
August 4th, 2014
Managed Care FAQs
By Wyn Staheli, Director of Research | Published August 4th, 2014 - Last Review/Update March 5th, 2019
The following frequently asked questions (FAQs) are adapted from the American Pyschiatric Association (APA). It is relevant to all types of providers with questions about managed care.
Q: I am having a problem getting in the network of managed care company X. They have a contract with a major employer in the ...
July 24th, 2014
Are Medicare fees going up? Or down?
By | Published July 24th, 2014 - Last Review/Update January 25th, 2017
PAMA (up 0.5%)
On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014 (PAMA). Within this law, Congress instituted changes that went into effect on July 1, 2014. The law provided for a 0.5% update for claims with dates of service on or after ...
March 2nd, 2014
Will mandatory Medicare payment cuts (due to the SGR) get repealed?
By | Published March 2nd, 2014 - Last Review/Update January 27th, 2017
Since 2003, healthcare providers have been dealing with the the short term patches to the Medicare payment system. After all this time, it now appears that Congress is making a move to address the ongoing issues with the Sustainable Growth Rate (SGR). This is the formula that has caused the payment problems with Medicare. Many professional organizations are endorsing the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015, S. 2000) and encouraging providers to contact their congressional leaders and lend their support for this legislation. If you wish to join those lending their support CLICK HERE for a helpful tool to contact YOUR congressional leaders.
Read More
February 12th, 2014
PPACA Grandfathered Plans
By | Published February 12th, 2014 - Last Review/Update January 27th, 2017
When discussing the changes to health insurance plans due to the Patient Protection and Affordable Care Act (PPACA) of 2010, the subject of "grandfathered plans" has been in the news lately. Plans that do not undergo "substantial changes" are not required to meet the requirements of the PPACA. So the question that arises is, what is a substantial change and what is a non substantial change?
June 21st, 2010
Medicare Fee Alert-June 21, 2010, by Dr. Ron Short
By | Published June 21st, 2010 - Last Review/Update January 27th, 2017
Congress continues to debate the elimination of the negative update that took effect June 1, 2010. The CMS is hopeful that Congressional action will be taken to avert the negative update.
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