Prospect is not sending EOBs anymore as of 09/01/17

Hello everyone! Just a quick public service announcement. 

Prospect, and all of the IPAs that it administers, will not be sending paper EOBs anymore. The claims and authorizations website doesn’t have them in a way that is easy to get by date, so you need to sign up with your clearinghouse to receive the 835 ERA files. 

Those IPAs include: 


Nuestra Familia



Pomona Valley Medical Group aka PVMG aka ProMed

Upland Medical Group

This DOES NOT include Prospect LA Care because that is administered by MedPoint Management. Because why not. 

I use Office Ally, so, that is the only one I will really be able to help you get enrolled with. Here is the 835 ERA form  that you would need to fax in to get your EOBs electronically. 

If you use a different clearinghouse, call them to get the proper forms. Some of you may have billing systems that handle your claim, eligibility, and ERA set up on your behalf with the clearinghouse. Not a comprehensive list by any means, but if you use Advanced MD, WebEDoctor, or Athena, you need to call your software support people directly, and the sooner the better. 

This is really for my Southern California providers and billing services. Heads up guys. 


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Filed under HMO, Medical Billing, public service announcement

Any anesthesiologists in the house? And by “the house” I mean California.

I don’t know how many of my California anesthesiologist readers are contracted with Medi-Cal, but I am sure there are a few of you. 

I am also sure that you know how little they pay you. But, I have recently figured out a way to get them to pay you a small amount more. 

Usually, Medi-Cal will only pay for anesthesia for one service per day. It had never mattered that the anesthesia was for a different surgery at a different time on a different body part. 

But in 2015 CMS started using the X (EPSU) modifiers. Applying them to the appropriate line item has allowed me to increase my provider’s reimbursement from Medi-Cal to all line items submitted on the claim. The modifiers are as follows: 

  • XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
  • XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
  • XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
  • XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

Use the modifier on the line that pays less, just in case the automatic processing system decides it hates your particular claim. Also, since Medi-Cal does not accept more than one modifier per line, remember to use your 99 and indicate the modifiers in box 19. 

Call or email with any questions. 

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Filed under Anesthesia, Medi-Cal, Medical Billing, Modifiers

When Medicare says 365 days, they mean 365 days.

Gentle readers,

It is flu shot season. And do-the-physicals-on-your-Medicare patients-before-they-go-somewhere-else-and-another-office-bills-the-physical season. And I am seeing a lot of the same question from both my billing service providers, and from you, my gentle readers.

Specifically, you billed/coded the flu shots and physicals the way I taught you and they are still getting denied! What gives?

And here is your unfortunate answer.

Medicare will pay a flu shot once every 365 days. They will pay a physical once every 365 days. They will pay a pap once every 730 days for a woman at normal risk and once every 365 days for a woman at high risk. They will pay the pneumo vaccine once every 365 days.

That means that if a patient came in on Feb 17th 2016 to get their flu shot last year and then came in this year on Jan 25th and got another flu shot, you will not get paid. Even if you bill with ICD10 Z23. Even if you bill with the Q-code for the vaccine. Medicare does not care that it is a different flu season. They do not care that your patient will be visiting their newborn grandson in a couple weeks and they need to be up to date on their immunizations. They do not care that your patient is going for a month long cruise in the caribbean and this is the last date they have available until they get back and they would prefer to get it done before they are rubbing elbows with a bunch of strangers who may have the flu.

Medicare does not care.

And they really mean 365 days. Not 364. So, when a patient needs a preventive service, please try and train your doctors and your office staff to check the date the patient received their last preventive service. The Medicare site also has a tab under the eligibility lookup section to check and see when the patient is next eligible for a preventive service. Here is a screenshot of the page and what it looks like:


As you can see, the date the patient is going to be eligible for any specific service is indicated on the right. Flu and Prevnar are not included in this list, so you will need to rely on your records to track those. 

Below is the link to a good website for more information on the Medicare policies for preventive services.

Keep emailing your questions and I’ll keep giving you answers. 



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Filed under Flu Shot, Immunizations, Medical Billing, Medicare, Preventative services, Vaccinations

Heads up for my ophthalmologist friends

Hello my ophthalmologist friends!

Medicare is changing the rules for the 92235 and the 92240. Up until 2017 we would bill two line items of those codes with RT/LT modifiers. According to the new edits, as of 2017 those codes are bilateral. If you separate them and use the RT/LT modifiers your claim will be denied. 

If you already sent them that way, you can use your local Medicare site to do a simple claim correction and get that updated. 

For the FA and the ICG this year, you bill just one line item with no modifiers. And, yes, we will get paid less. 


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Filed under CMS, Medical Billing, Medicare, Modifiers, ophthalmology

Free MACRA training – Additional dates

Hi everyone! With the responses we received from our providers, we scheduled the following webinars. Please be aware we are on western standard time, so, my wonderful readers from the other time zones,  please take that into account. 
Friday            01/06/17       5:30 PM
Saturday       01/07/17       10:00 AM
Monday         01/09/17      8:00 AM
Wednesday    01/11/17      12:00 PM
Friday            01/27/17       5:30 PM
Saturday       01/28/17       10:00 AM
Monday         01/30/17       8:00 AM
Wednesday   02/01/17      12:00 PM
Reserve your spot by calling me at (909) 374-5439 or emailing
You can also call Kelly at (909) 861-1357 or email her at
This is SUPER IMPORTANT and free. And it will fit in your schedule! PLEASE do not let your provider lose lots of money because he didn’t know what he needed to implement in time. See you there. 

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Filed under Medical Billing

Have you heard about MACRA?

MACRA is the law that congress passed regarding Medicare in 2015. I found out about the new legislation a couple weeks ago. And, I have to tell you guys, I am not excited. 

There are going to be a LOT of changes coming for providers once the law goes into effect in 2019 and small practices will be bearing a considerable burden. 

But you all know that I would not be posting scare tactic articles here about something that won’t happen for over two years. So, the statistics that determine whether your providers (or you, if you are a provider) are going to get penalized up to 9% are going to be drawn from self reported data from 2017.

That means that in order not to be penalized in 2019, you and your providers need to make changes as of the 1st of the year. In two months.

New Generation and our sister company, J&J Billing, Inc. are putting on four free one hour trainings. Normally we charge for our webinars, but it is so important that providers know about MACRA and the changes that are coming, that we are waiving the fee. So, fill this form out, and fax it back to me and I will make sure that the online classes we schedule will accommodate everyone .

MACRA Training Availability Form

Fax (909) 367-2922

I will post the final schedule on the blog once we have all the feedback. You will need to email me to sign up for the class. I am working on a fancy-pants sign up sheet for my classes, but it is still quite a work in progress. I am a very good biller and a very bad coder. 

Seriously people, print the form, send it back. This is free. You NEED this information. Tell your friends. 



Filed under CMS, Doctor's Office, MACRA, Medical Billing, Medicare, Online classes

Please send good vibes (and referrals!) our way.

One of our providers is moving to Indiana. He is joining another group practice. They have an established, well run, in-house billing set up and they are not willing to uproot their entire system, and just hand it over to an unknown business 2,000 miles away on the say-so of their newest physician. You and I can all agree that is totally unreasonable, but that is the situation I am in right now.

He will be very much missed (as a person, not just a paycheck), and we would very much like to replace his business before he leaves in a couple months. So, all my readers, please keep me in mind and send good vibes and referrals my way. If you know anyone who wants an experienced, knowledgeable billing service with a great reputation, please give them my number or email. (909) 374-5439, 

We do billing for ophthalmologists, ENTs, cardiologists, psychs, family practice, urgent care, anesthesiologists, dermatologists, allergists, physical and occupational therapists, and OBGYNs, and more. In our 15 years in this industry we have billed for every kind of practice imaginable. 

Except dentists. Sorry. I don’t have the right software for dental billing.

Thank you all so much in advance. 



Filed under Medical Billing