Category Archives: Uncategorized

Getting Contracted

For most doctors, contracting with insurance companies is a necessary evil. Well, maybe not evil. But is is a giant pain in the neck, and it is necessary. Some doctors hire a company that specializes in contracting, some of them pay their billing service to do it, some doctors give the responsibility to their office managers, and some do it themselves. So, you have options.

However, what I am realizing is that a lot of physicians have an unclear view of the process of becoming contracted and how they will end up getting paid once the contracts are in place. Unlike my normal posts, where I can give you a run through of how everything works on a basic level and then invite you to call or email if you have any specific questions, I am going to have to jump right to the second step. I have encountered too many misconceptions to be able to clear them all up in one post.

What I can do is give anyone who calls or emails a brief run down on contracting with Medicare, Medicaid, PPO insurances, and HMO insurances. I can explain about the CAQH, and alert you to the common pitfalls that people run into when applying for a contract. If you need to know how the payment process is supposed to work once you are contracted, we can go through that as well. I don’t mind taking 15 minutes of my time to help someone else avoid hours and months of losing money. And if you should happen to mention my blog to your doctor friends, we can call it even.

If anyone needs help with actual contracting, call me as well. I’ve worked with a couple of companies that are very good and very professional, and I will be more than happy to pass their names on to you.

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Medicare PQRS reporting

****01/07/17 Update**** If you are looking at this article, Medicare will be replacing these rules soon. Please see my articles and webinars on the new Medicare called MACRA***

As most of you know, I try and give you the benefit of my experience. And sometimes, that experience comes with a very painful lesson that I am trying to help you avoid. Such as this one.

We have several doctors who have not been using the Medicare PQRS codes. For those of you who haven’t heard of these before, that stands for the Medicare Physician Quality Reporting Services, and “PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of quality information by individual EPs and group practices.” That quote is from the 2015 PQRS Implementation Guide. This is a very long document that will explain what the program is, why Medicare is doing it, and most importantly, what happens when doctors don’t use these new codes.

If your provider has not been using the PQRS codes, Medicare will be garnishing providers checks 1.5% this year and 2.0% for all subsequent years. However, the garnishment taken in 2015 is a result of 2013 PQRS reporting, and the garnishment that will be taken in 2016 is a result of your 2014 reporting. So, if, for the last two years, your provider has not used these codes, her Medicare checks will be subject to a “negative payment.”

Each type of provider has different PQRS codes that they are eligible and responsible to report. The codes are usually five digits total with four numbers first and then a letter, or they have the letter “G” first, with four numbers following. Please review the 2015 PQRS Individual Measure Spec Manual and the 2015 PQRS Individual Measure Spec Manual to find which codes apply to your physicians and what documentation needs to be included in the office notes to justify the service.

So here is what a charge that includes the PQRS codes would look like:

DX                                                                           CPT                                                                     Charge

715.09     724.5      244.9                             99213                                                                     $100.00

715.09     724.5      244.9                             G8427 (medications reviewed)                  $0.01

715.09     724.5      244.9                             1036F (non-smoker)                                       $0.01

Total Claim Charge:  $100.02

When you send those codes on your claims, they aren’t going to get paid. Medicare wants us to send them in with a charge of $0.01. These charges are for informational purposes only and you will end up writing them all off. Again, Medicare is NOT going to pay for them. They are required codes they will penalize you for NOT using, but they will not pay a single penny extra for these line items. Literally, not one penny. If you are not using these, please start ASAP to prevent negative payments in future years. If you are, tell everyone you know.

As always, if you need any additional help or clarification, or if you have some information I don’t, please email or call me at (909) 374-5439.

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ICD10 Free Online Seminar 02/20/14

Good news everyone! My software vendor, Advanced Data Management, is hosting a free Get-Prepared-for-ICD10 seminar for their customers and associates. And they have extended that offer to my customers and associates. Details below and sorry for the late notice.

Welcome to Advanced Data Managements free ICD 10 Webinar. The topic is Be Prepared, Not Scared, and the presentation should take about 30 minutes.

Please Join Us…

Thursday, February 20, 2014 1:00 pm, Pacific Standard Time (San Francisco, GMT-08:00)
Thursday, February 20, 2014 3:00 pm, Central Standard Time (Chicago, GMT-06:00)

To join the online event
At least 5 minutes before the starting time:

1. Go to
2. On the Event Information page that appears, click “Start Now”.
Teleconference information
To receive a call back, provide your phone number when you join the event, or call the number below and enter the access code.

Call-in toll-free number (Premiere): 1-877-684-9625

Audio Passcode: 446500

Kelly Piatt

Advanced Data Management

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Timely filing limits

One of the things we try and do to make sure we receive maximum reimbursement is to make all of our reference material easily available, and update it often. Like you know, I have been doing this for over 10 years now, and I have a LOT of information in my head. But my head is also significantly slower to update than the insurance companies, so I make sure that I have lists and spreadsheets with anything that will help make follow up easier. What I tell my trainees is that the rules change around here every 10 minutes because we have to constantly update to changes the insurance companies and the AMA are throwing at us.

Recently, we went through and updated all of our timely filing information guidelines for the insurances we deal with most. Here is the list for you guys. If there is anything you want added to the list, just use your Excel or Open Office program and insert those lines. We also included the timely filing limits for appeals, to make this tool actually useful. For those of you using keywords to search, this list includes timely filing information for Blue Cross, Apple Care, Blue Shield, TriCare, Cigna, Health Net, Medicare, Medi-Cal, and a couple dozen others.

Please click here to view or download the Timely Filing Guide . I also added this to the reference page for you. Please remember, if you bookmark any page on this blog, that would be the best one.

Share this with your friends and call or email if you have any questions or want any one on one or office wide training. (909) 610-9524. As always, thanks for reading.

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Filed under Billing, Consult, Medical Billing, Timely filing, Uncategorized

Please post your payments

This is along the lines of the cash in the office post. One of my doctors has lost an insane amount of money, and I would like you all to learn from his mistake.

I have a small Internal Med with an emphasis in Cardiology in Montclair. I go to their office once a week, after hours, and do all the charges and claims in about an hour. This isn’t bragging, they are small, and I am fast, and they only have me enter charges and send electronic claims. I have been doing their billing for four years and, until recently, I had never even seen one of their EOBs. They don’t want to pay me to post the payments, because they think it will cost them too much money.

I finally signed them up for a user name and password on the Online Provider Services Medicare website, against the office manager’s strenuous objections. On the first EOB I pull up, I immediately notice that ALL the EKGs I billed had been translating as 93005 instead if 93000.  The reimbursement for a 93005 is $8.93 (allowed $11.16 minus the 20% coinsurance) and the reimbursement for the 93000 is $15.14 (allowed $18.93 less $3.79 for the coinsurance). That means my Internal Med has been losing $6.21 on every EKG for at least the last four years. He probably does 20 EKGs per week. So, ($6.21) x (20 EKGs per week) x (52 weeks) x (4 years) = $25,833.60. This does not account for the fact that over the last four years Medicare reimbursements have been decreasing.

Even after this, I have not been able to convince them that it would be more cost efficient in the long run to have me post the payments as well as the charges. Please, please, please use this as a warning and properly reconcile your EOBs with your payments. Every EOB for every charge.

Also, do it by line item and not by charge, because it is too easy to miss something important. Something like this.

$25k. Gah.

P.S. If you have any questions about what you should be getting paid for things, use the Medicare Fee Schedule Look-Up. Most companies will pay a similar amount, so you are mostly safe using that as a standard.

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