Category Archives: Doctor’s Office

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

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

I am going to save you six hours of phone calls to insurance companies. Aren’t I wonderful?

One of our providers recently moved. Those of you who have gone through this can commiserate with me.

Six hours of phone calls,faxing, and emailing later, her address was updated with the insurance companies. Mostly.

So, I am going to give you the results of our efforts in blog form and again in spreadsheet form. Yay, spreadsheets! If any of you out there have other contact info for the provider relations/ credentialing/provider demographic update departments for any other insurances, please leave a comment or shoot me a quick email.

Medicare and Medicaid require that you send them an application form to update your servicing location. If you are an individual provider, send Medicare a cms855i and if you are a group, send in a cms855b. If you don’t know whether you are an individual or a group, call provider enrollment. For Medicaid, I suggest calling your individual state Medicaid and having them direct you to the proper form. I also put the Medicare forms on the new and improved links and tools page.

The rest of the insurances simply need an updated W9 form.

Aetna – Update on Aetna.com. Here is the direct link: http://www.aetna.com/docfind/custom/provider/data_correction.html

Blue Cross – Fax W9 to (818) 234-2836, attn: Anthem Provider Database Management.

Blue Shield – Fax in a W9 to (916) 350-8860, attn: Blue Shield Provider Contracting

Caremore – Fax W9 to (562) 977-6141, Attn: Caremore

Cigna – Email attached W9 to intake_pbm@cigna.com, subject line: Provider Practice Address Change

Health Net – Fax form to (877) 897-7910, Attn: Health Net PDM

IEHP – Email the provider Service Representative for your city. You will need to call them and get that info. The only one I have is for Montclair, CA and that probably won’t help most of you.

Inland Valleys IPA – Fax in your W9 to (213) 830-1815, Attn: Inland Valleys IPA

ProMed/Upland Medical Group – Even if you have more than one IPA contract with a group that ProMed administers, one fax will update everything. So, fax the W9 to (714) 667-8156, Attn: ProMed

United HealthCare – You can either fax or email the update. The email is phshpdemo@uhc.com and the fax is (855) 314-6844

I have also included all this information in beautiful spreadsheet form. Here is the Health plan updates spreadsheet.

You’re welcome  🙂

As always, if you have any questions or anything to add, email or comment.

 

 

 

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Filed under Billing, Doctor's Office, Medical Billing, Office policy

How to bill Medicare HMOs

I know that is a very ambitious title, but a few people here have been emailing me with questions on this topic. I figure, if a few of my readers are taking the time to email me, then there are far more of you out there with questions. The good news is, the answer is fairly simple.

The emails I have been receiving fall into three main categories.

1. How do I bill a pap smear to a Medicare Risk HMO?

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

3. When Medicare says a patient has an HMO, is Medicare secondary?

And here are your answers:

1.  How do I bill a pap smear to a Medicare Risk HMO?

As you might remember from my previous post, Everything you ever wanted to know about pap smears, each HMO has its own way of doing things. Some want the diagnosis V72.31, others want V76.2. Some want to follow Medicare rules, and some want to pay with the preventative code.  Some won’t pay anything at all, instead they capitate it. The best way to find out how your HMO will pay your provider’s claim is to get a copy of the provider’s contract.  

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

By and large, the Medicare Risk HMO plans want us to use the Medicare codes for the flu and pneumonia substances. For the flu, use the Q-codes for the substance and the G0008 for the administration. For the pneumo, use 90732 for the substance and G0009 for the administration.  For a more thorough explanation, go take a look at my Medicare and Immunizations post.  Please remember, not all IPAs have the same fee schedule. If this doesn’t work, a quick call to the provider relations department will point you in the right direction.

3. When Medicare says a patient has an HMO, is Medicare secondary?

No.

Please, let me reiterate.

No. The HMO replaces the patient’s Medicare. The claims go to the HMO. We have to follow the HMO rules. The patient may have a copay and you may need an auth. I am training a front desk right now, and this is the policy I have in place.

If a new patient calls to make an appointment, check the insurance online while the patient is on the phone. It takes 30 seconds to check Medicare on the Noridian Endeavor site. If the patient has an HMO, make a note on the schedule and ask the patient to bring in their HMO card as well as their Medicare card.

If an established patient is returning to the office, go online and check the Medicare eligibility. The status of a patient’s Medicare can change month to month. PLEASE do not assume that if a patient had straight Medicare last month, he will again this month.

Once the doctor performs the service, good luck trying to collect from the patient. People hate to pay after they have already received their service.

So, as always, if you have any questions, please call or email. If you want us to come into your office and train your front desk or your billing department, we can do that. We do on-site training for those in our area and online training and Skype conferences for our far away clients.

EDIT: I have had a couple people ask me what you can do when you see the patient before you find out they have a MR Risk HMO.  You can try billing the patient your cash price. Or, you can send the claim to the IPA (medical group) with your medical records attached asking them to review the charge for a retro authorization based on medical necessity. In box 19 on the physical claim form write “please review notes for retro authorization.” I also like to send a letter. Here is a good example of a medical necessity template appeal letter. And everyone who gets paid due to this can thank Molly and David for their rather pertinent emails.

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Filed under Billing, Doctor's Office, Flu Shot, HMO, Medicare, Pap smears, Pneumo, Vaccinations, Well woman exam

Modifiers 24 and 79

A few months ago we had to do some training on our ophthalmologist account regarding when to bill the 24 modifier versus the 79 modifier in the global period to a surgery or in-office procedure. I figure, if our employees are having questions, some of you might be too, and I want you to get the maximum reimbursement for your services. First, the exact descriptions of the modifiers from the CPT book:

24 – Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Post-operative Period:
The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:
The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

Many of our doctors do both minor and major surgeries, and we all know that patients need to come back in for follow up care on their various incisions, wounds, and ulcers to make sure everything is healing properly. The insurance companies will not pay for these follow up visits, or any visit done in a certain amount of time after the procedure without the proper modifiers as they consider the follow up visit to be an integral part of the original procedure. This time period is called the global period and the length of time varies depending on the procedure performed.  The issue with this no-payment rule comes in when the doctor diagnosis the patient with something additional during the follow up visit, or the patient needs another procedure. At that point, the doctor needs to do a complete visit including review of systems and exam and make a medical decision, and we can all agree that she should be paid for that. Here is how you get her paid. Modifier 24 goes on the office visit and you make sure you have a primary diagnosis that is different than the diagnosis on the original procedure. If the patient needs any in-office procedures, put a 79 on the procedure and make sure the diagnosis is different than the one on the original procedure. If the patient needs another major surgery in that time period, unrelated to the original, use modifier 79 as the first modifier on the surgery.  Just to avoid confusion, whether you use the modifier 24 or the modifier 79, the modifier would go on the visit subsequent to the surgery or in-office procedure.

To answer a popular question, yes, you can use modifier 79 when you are billing for the same surgery on a different body part. For example, if the patient had a cataract surgery on the left eye in January and he is getting cataract surgery on his right eye in February, you can use the same diagnosis of cataracts, the same CPT code for the surgery, and add the 79 modifier. Here is how that would look:

Date                          ICD9 code            CPT Code    Modifiers

01/13/14                 366.17                    66984             LT

02/18/14                366.17                    66984              79    RT

As for using the 24 modifier, there are all kinds of good, justifiable reasons to bill with that modifier and get your office visit paid separately. Here are just a few:

1) Patient is requesting a refill on medication for her chronic condition (hypertension, diabetes, hypothyroidism, migraines, neuralgia)

2) The patient came in with an unrelated chief complaint on his follow up visit

3) Patient came in for the follow up and the doctor identified symptoms of something else during the exam

This is by no means a comprehensive list, so if you are not sure whether or not your particular patient meets the requirements for using a 24 on the office visit, send me a quick email and I’ll let you know how I would bill it. Here is an example of how a charge like that would look.

Date                          ICD9 code                             CPT Code    Modifiers

01/13/14                  366.17                                    66984             LT

02/18/14                 250.60    362.01                  99214             24

I also have another chart for you (I love charts!) detailing the global period for each procedure. It is LONG. I do not suggest you print this one out, but save it on your own computer for reference. Oh, and, the global period for any given code is either going to be 10 days or 90 days, if it has one at all. FYI. As always, I saved the chart to my Links and Tools page for you.

EDIT: Just a quick FYI, global surgery rules do not apply to assistant surgeons. So, anyone who is billing a code for a provider assisting with a surgery, these rules don’t actually apply to you. Just go ahead and use modifiers 80-82 the way you’ve been doing. In fact, if we do send in a claim with modifier 79 (or 78 for that matter), the claim will actually be returned as unprocessable. Thank you, Adam, for helping to clear up the confusion.

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Filed under Billing, Claims, CPT, Doctor's Office, Follow up, Health Care, ICD9, Medical Billing, Modifiers, Office Visit

Modifier 25 and 59 update

I have an Updated modifier chart for you guys. We have been finding that the insurances are denying the immunization administration (90471) without a 25 modifier on the office visit and a 59 on the 90471. If you were using the old one, please replace it with the updated rules. For a more detailed explanation of how these modifiers work, please see the post from 01/11/13.

And this new chart is fancy and it’s typed and has examples. Hope it helps. I have also had a few inquiries on when to use the modifier 24 and 79, so my next post will be about how to use those effectively. Also, if anyone has a question for us, please do not hesitate to email or comment.

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Filed under 96372, Billing, Claims, CPT, Doctor's Office, Medical Billing, Modifiers, Office Visit

Quick Workers Comp Tools

Have you ever wished that you could have a list of all the lists and tools and links you need for Workers Comp in one place? Well now you can! You’re welcome.

Doctor’s First Report

PR-2 Report

OMFS Schedule

OMFS DME Prices

NDC Numbers for substances

OMFS Fee schedule for pharmeceuticals

EAMS

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Filed under Claims, CPT, Doctor's Office, Follow up, Health Care, Medical Billing, OMFS, Workers Compensation

Medi-Cal and Psychiatry (Tip: It’s a Mess)

If your psychiatrist is contracted with Medi-Cal, you are probably beating your head against your desk in frustration at this very moment. I know I am. This post will attempt to make your life easier and save you the headache when it comes to billing for your Medi-Cal patients.

First things first. Medi-Cal does not cover psych services directly EXECPT when the patient is mentally retarded. That means your claim needs to have an ICD9 code between  317 – 319. If your patient is mentally retarded, you can send a claim directly to Medi-Cal and they will pay you. But only with 2012 codes or office visit codes. Medi-Cal hasn’t updated to the new 2013 codes for psychiatrists.

Treatment for any other diagnosis carves out to the county. Please note, this is NOT the county the patient currently resides in. The claim goes to the county of origin. Which you can find on your online Medi-Cal eligibility verification sheet. If you do not have online access to Medi-Cal eligibility, I suggest you stop reading this post and go sign up. Remember to come back though. The explanation gets more convoluted. Once you’ve determined where the claim should be filed, please also make sure your provider is properly contracted with the individual county plans. If she is a Medi-Cal provider but her Los Angeles County Mental Health contract has lapsed because the office manager did not do the credentialing in a timely manner, your claims will not get paid. For example.

If a patient walks in with a Medi-Cal based HMO such as IEHP or Blue Cross, the claim also goes to the county. However, if the plan is based on the Healthy Families program or a DualChoice program with Medicare and Medi-Cal combined, you would need to call the health plan to determine where to send the claim. And I am sorry, but there is no quick and easy guide for that; the claims address and financial responsibility for mental health depends on the individual plan.

For mentally retarded patients with Medi-Cal based HMOs, the claims STILL go straight to MC. Even if your office manager gets an authorization from the health plan, send your claim directly to Medi-Cal. I have attached a small flow chart  to help you get your claim to the correct place along with a list of county mental health carve outs. Unfortunately, I can only include the carve outs I have worked with.

So, any of you out there with carve out information not on this list, please shoot me a quick email at newgenerationbilling@gmail.com or comment on this post so I can add it. I will add the flow chart and the county carve out list to the links and tools page. Remember, if you are going to bookmark anything, the links and tools page would be the smart way to go.

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Filed under Authorizations, Billing, Claims, County carve out, Doctor's Office, Medi-Cal, Medical Billing, Psych

Everything you ever wanted to know about pap smears

**DISCLAIMER**  

***This post was written in 2014 and the rules have changed since then. I am going to be putting up a new post with the new rules updated to ICD10 very soon. There are some major changes to the way the insurances accept the charges and this an old post with the old rules. If you have any questions, and can’t wait for the new post, please email me directly and I will try and help you out.*** 

The first thing about paps is that every insurance pays them differently. To tell the truth, I don’t have most of it memorized. What I do have is a binder, with one page per insurance, and all of the pap rules are laid out there, in alphabetical order.

Of course, I’m going to give those to you. I suggest you do what I do and put them all in a three ring binder. However, I can only give you the PPO pap smear rules, because your HMO contracts will not be the same as the contracts for my doctors. I can show you a few of my HMO rules, though, so when/if you make your own reference sheets you know what the necessary information is.

You CAN get an office visit and a pap smear paid on the same date on the same claim. You just need to use proper modifiers. Also, most insurances allow patients to self refer for their annual exam, so you shouldn’t have to worry about authorizations.

Here are the Pap rules for PPO insurances. For your HMO insurances, all you need to do is call the provider relations department and get a copy of the doctor’s contract. The contract will be fairly short, and very clear about which codes are paid. However, you will need to ask the provider relations people which diagnosis they need to see on the claims.

If you want to review the high risk rules you can find those on the MR website. Here is a link, for the curious.

Remember to follow the blog; you’ll get an email every time I get a new post up. Also, if you have a specific question, please don’t hesitate to email me.

 

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Filed under Billing, Claims, CPT, Doctor's Office, Health Care, ICD9, Medical Billing, Modifiers, Pap smears, Well woman exam