Insurance Articles & Resources

When it comes to healthcare, insurance is all about reimbursement. There are thousands of third-party payers/payors and it is up to each organization to understand the rules and regulations to ensure proper reimbursement.

Please see the “Guide” section for more information about specific types of insurance plans (e.g., traditional, Medicare, Workers Compensation).

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Nov 5th, 2024

Designation of Authorized Representative for Appeals

A Designation of Authorized Representative is a formal document (form) that allows a third party, such as a friend, family member, attorney, or healthcare provider, to act on behalf of the patient/beneficiary in handling specific aspects of an insurance claim or appeal
Aug 1st, 2022

CMS Started to Enforce Applicable Price Transparency Requirements

by  Amanda Ballif

Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.
Jul 28th, 2022

Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule

by  Amanda Ballif

The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments on proposed changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues effective on January 1, 2023 and thereafter. The Calendar Year (CY) 2023 PFS proposed rule is one of several proposed rules aimed at increasing equity in health care.
May 11th, 2022

HHS’s New Mental Health and Substance Use Disorder Benefit Resources Will Help People Seeking Care to Better Understand Their Rights

by  SAMSHA Newsroom

New Resources to Help People Seeking Care to Understand and Access Protections Offered Under the Parity Law for Mental Health and Substance Use Disorder Benefits
Dec 26th, 2017

CHIP Reauthorization for 2018

by  Jared Staheli, MPP

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 ...
Nov 28th, 2017

Medicare Expands Value Based Plans

by  Wyn Staheli, Director of Content - innoviHealth

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 ...
Jun 28th, 2017

Medicare Announces New Cards to Be Issued

by  Mario Fucinari, DC CCSP CPCO MCS-P MCS-I

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.
Feb 6th, 2017

Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?

by  Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC

We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?
Dec 11th, 2015

The Benefit of Checking Benefits

by  Fabrienne Castro

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...
Jul 9th, 2015

Deductible and Coinsurance Application for Laboratory Tests (Rev. 2581, 04-01-13)

by  Jared Staheli, MPP

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 ...
Aug 4th, 2014

Managed Care FAQs

by  Wyn Staheli, Director of Content - innoviHealth

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 ...

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Jun 7th, 2023

PI Medical Necessity verses Healthcare. The difference you make is life changing 

by  Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education

The presenting problem as opposed to the causation. Your choice of wording will make a valid compensation claim or kill it. With a career caseload of over 3500 claims, I’ll introduce you to my format of good case write-ups that have won substantial new money for victims and their families and has been kind to me as well.

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