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:

medicare-prev-screen-shot-1

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. 

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

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. 

Sorry. 

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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 newgenerationbilling@gmail.com
You can also call Kelly at (909) 861-1357 or email her at kelly@adm1inc.com
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. 

 

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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, newgenerationbilling@gmail.com. 

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. 

 

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Filed under Medical Billing

Every practice does it…

I was debating continuing the joke into inappropriate-land, but my professionalism got the better of me.

By “IT” I mean, no matter how careful the front desk is, the doctors occasionally see a patient that has an insurance the doctor is not contracted with. If you have a lot of non-contracted patients slipping through, please read my post on how to run a tight ship at the front desk. The purpose of this article is not to cast blame, but to help you deal with the inevitable insurance fight that will result when this does happen.

Just like all posts, this will have a detailed article and a summary wrap up at the end, and a downloadable guide. If you are looking for particular information, try pressing CTL + F and a little search box will pop up. Put a one to two word search query there and press enter. You should jump directly to the part of the post that applies to you.

The BEST case scenario when you end up with an out of network patient, is that they have a PPO, Managed Care (MC), or Place of Service (POS) plan with out of network benefits. The patient will end up paying more toward their coinsurance or deductible, which, you know, sucks for them, but the allowed amount for the provider will be the same as the in network rate.

If the non-contracted insurance is an EPO, the patient has no out of network benefits. No matter how much you appeal, you will not get any payment from this insurance. Now you have to break out your flow chart. If the patient doesn’t have anything secondary to their EPO, you bill them your cash price. Or the full price. Whatever. You do you. If the patient does have a secondary, you send a claim to the secondary with a copy of the primary denial and hopefully you are contracted with them.

Here is where it gets a little complicated. If the patient has a commercial HMO, there are a ton of rules the IPA will cite in order to deny your claim. And, if the patient does not have a secondary insurance, you can decide how much effort you are going to put in trying to get the insurance to pay your claim. You can bill the patient right away or you can appeal the charge to the non-contracted IPA. I, personally, will fight with the insurance company for a couple of rounds before I bill the patient. A patient who has insurance is very unlikely to pay your bill, even if they legitimately owe it. A patient who has an HMO generally has less money in their budget then someone who has a PPO or EPO and is even less likely to pay your statement. Here are your options with a commercial HMO patient.

  1. You are a family practice/internal med contracted with the IPA, but you are not the PCP. Unfortunately, in this case, there is probably not much you can do. You can try sending a claim to the claims department with the medical records and a letter requesting retro authorization. Here is an example of a letter requesting retro authorization. You would update the letter to explain what happened in your case. I have not had much success in convincing the insurance to pay in this situation. Mostly because the IPA has ALREADY paid the other provider their cap for that patient for the month. They are not going to pay you another cap payment, and they REALLY don’t want to pay you fee for service. 
  2. You are a family practice/internal med and you are not contracted with the IPA. You have a better shot in this situation getting a retro auth from the insurance. You would use the same type of letter as in the above example. I have about a 70% success rate when this happens. 
  3. You are a specialist and you did not get an authorization. Whether or not you are contracted, you have about the same chance of getting paid if you did not get a prior auth or single case agreement. You write a letter to convince the insurance that the services were medically necessary, or urgent. 

One of the most complicated situations arises when a patient comes in and hands you a Medicare card, but it turns out they actually have a Medicare Risk HMO plan. If the patient does not have a secondary, you would handle the charge in one of the ways outlined above. However, most of our patients with MR Risk HMO plans, also have Medicaid secondary (called Medi-Cal here in California). If your provider is contracted with Medi-Cal you are not allowed to bill a patient under any circumstances. It does NOT matter that the patient went to the wrong doctor, it does NOT matter that they gave you the wrong insurance, it does NOT matter that they specifically withheld information regarding a primary insurance, it does NOT matter that the insurance they became effective with on the first of the month when you saw them is not one you are contracted with, it does NOT matter that you requested an urgent auth and the insurance denied it. Medi-Cal does not care. My out of state readers will have to let me know if your Medcaid works the same way, but that is how it works here. Also, Medi-Cal has been forcing people into HMOs as well. So what often happens, is that a supposedly straight MR patient comes in, you bill MR and they deny it stating the patient has an HMO. You can’t send that denial to Medicaid because the secondary is also an HMO and you are not the PCP. And, unlike in the previous situations, you are not allowed to bill the patient. 

Here is an example of a letter that I have successfully used to get payment from an IPA in this exact situation. 

I have added all the letters to the links and tools page, and I have created this Downloadable non-contracted patient guide, to help you easily determine what you need to send where in which situation. If you need help with your specific patient, and your specific situation, send me an email.

If your office needs training or consulting or an audit, or if you decide that all of this is too much hassle and you want to pay someone else to do it for you, you can give me a call (909) 374-5439. I am awesome at this stuff. All the partners in New Generation are awesome at this stuff, actually, and we will train, consult, or bill, well, awesomely.

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Filed under Accounts receivable, Authorizations, Billing, Denials, Doctor's Office, Follow up, Health Care, HMO, Medical Billing