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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 ...
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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 ...
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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 ...
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By Christine Taxin | 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 ...
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CHIP Reauthorization for 2018
December 26th, 2017
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 ...
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Medicare Expands Value Based Plans
November 28th, 2017
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 ...
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Funding Extended for Veterans Choice Program
August 23rd, 2017
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 ...
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VA Patient-Centered Community Care and Veterans Choice Program: Worth it for Providers?
August 23rd, 2017
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 ...
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Veterans Choice Program
August 4th, 2017
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.
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Medicare Announces New Cards to Be Issued
June 28th, 2017
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.
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CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
February 15th, 2017
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.
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Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?
February 6th, 2017
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?
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Whiplash Damages
January 13th, 2017
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.
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Discounts
December 7th, 2016
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 ...
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Insurance Denying Everything as Maintenance
December 7th, 2016
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?
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How to Handle Billing for a Patient With Multiple Plans
October 11th, 2016
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?
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Consumer Directed Health Plans (CDHP)
September 17th, 2016
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 ...
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Government Healthcare Programs
September 17th, 2016
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 ...
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Q&A: Do you think insurances will continue to raise deductibles and copay/co-insurance amounts?
June 15th, 2016
By ChiroCode | 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?
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Groupon: Is it worth the risk?
May 26th, 2016
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.
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Medical History and Health History Forms
May 3rd, 2016
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 ...
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Provider/Patient Dynamic Changes as Result of High Deductible Plans
May 3rd, 2016
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.
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Mental Health Parity Information
April 5th, 2016
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.
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What is an 'Other Qualified Healthcare Professional'?
March 4th, 2016
By Wyn Staheli | Published March 4th, 2016
What's the difference between a physician, an other qualified healthcare professional, clinical staff and individual.
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The Benefit of Checking Benefits
December 11th, 2015
By Codapedia | 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...
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Essential Health Benefits (EHBs)
September 11th, 2015
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.
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Deductible and Coinsurance Application for Laboratory Tests (Rev. 2581, 04-01-13)
July 9th, 2015
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 ...
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Coinsurance and Deductible for the IPPE (Rev. 2159, 04-04-11)
July 6th, 2015
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, ...
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Deductible and Coinsurance for Prostate Cancer Screening Tests and Procedures (Rev. 1, 10-01-03)
June 29th, 2015
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.
...
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Deductible and Coinsurance (Rev. 1, 10-01-03)
June 26th, 2015
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 ...
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Waiver of Cost Sharing Requirements of Coinsurance, Copayment and Deductible for Furnished Preventive Services Available in Medicare (Rev. 2233, 06-28-11)
June 25th, 2015
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 ...
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MAC Jurisdictions Resources
February 10th, 2015
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 ...
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Discounts by ChiroCode
January 8th, 2015
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 ...
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Who Has Dental Coverage?
October 9th, 2014
By Christine Taxin | 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 ...
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Managed Care FAQs
August 4th, 2014
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 ...
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PPACA Grandfathered Plans
February 12th, 2014
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?
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