Insurance Articles & Resources

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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.

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.

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

Answering the Question: Does my Insurance Cover Chiropractic Care?

by  Wyn Staheli, Director of Content - innoviHealth

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.

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

What is Medical Necessity and How Does Documentation Support It?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

Understanding NCCI Edits

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

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 ...

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 ...

Veterans Choice Program

by  Wyn Staheli, Director of Content - innoviHealth

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.

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.

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?

Whiplash Damages

by  ChiroCode™

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.

Discounts

by  Wyn Staheli, Director of Content - innoviHealth

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 ...

Consumer Directed Health Plans (CDHP)

by  Wyn Staheli, Director of Content - innoviHealth

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 ...

Government Healthcare Programs

by  Wyn Staheli, Director of Content - innoviHealth

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 ...

Provider/Patient Dynamic Changes as Result of High Deductible Plans

by  Wyn Staheli, Director of Content - innoviHealth

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.

What is an 'Other Qualified Healthcare Professional'?

by  Wyn Staheli, Director of Content - innoviHealth

What's the difference between a physician, an other qualified healthcare professional, clinical staff and individual.

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...

Essential Health Benefits (EHBs)

by  Wyn Staheli, Director of Content - innoviHealth

Information about the mandated Essential Health Benefits (EHBs). Includes links and other helpful information.
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