Monday, December 18, 2017

OCMA Blog

Ensure your practice information is up-to-date with contracted payors

Physician Advocate Tip of the Month 

  • Reason #1 Up-to-date practice information such as specialty, address, tax identification number (TIN), practice name, and complete list of physicians in the practice (along with their national provider identification (NPI) numbers) ensures that payments and other vital contractual notices are received by the practice.
  • Reason #2 Providing updated, accurate practice information to payors ensures that your information is displayed correctly to patients looking for a physician through payors' provider directories. It also helps reduce the potential for delayed or denied payments for the practice.
  • Reason #3 It will likely keep your practice compliant with your contracts. Most payors have language in their contracts that requires physicians to notify the payor in writing of any changes in their practice. 

Be sure to download the free member resource "Updating Provider Demographic Information with Payors," at: www.cmanet.org/ces

Mitzi Young
OCMA Physician Advocate, CMA Center for Economic Services
(888) 236-0267
myoung@cmanet.org 

 


Physician Advocate Tip of the Month

Verifying your patients' eligibility and benefits in 2015 may save your practice thousands of dollars

Physicians are urged to be diligent in verifying patients' eligibility and benefits to ensure that you will be paid for services rendered. The beginning of a new year means that calendar year deductibles and visit frequency limitations start over. With open enrollment there may also be changes to patients' benefit plans, or they may even be insured through a new payor. 

Don't get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.
 
The new year also brings a host of other challenges that could affect your ability to be paid:  Read full article here.


Physician Advocate Tip of the Month: CPT® Modifier 22 – Reporting & Reimbursement

Tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.

CPT® modifier 22 increased procedural services allows a provider to gain additional reimbursement for an unusually difficult or time-consuming procedure. To realize that extra payment, your billing staff will have to make a special effort, as well.

Per CPT® Appendix A, modifier 22 may be appended to a CPT® code to indicate that the work performed was “substantially greater than typically required…. ” CPT® does not define a “substantially greater” effort, although some payors do offer guidelines (e.g., the effort and/or time to perform the procedure should be “at least 25 percent greater than usual”). Regardless of payor, you should append modifier 22 infrequently, and for only the most unusual procedures.

Specific circumstances that may call for modifier 22 include:

  • Intra-operative hemorrhage resulting in a significant amount of increased operative time.
  • Emergency situations that require significant effort beyond the normal service. This does not include minor intra-operative complications that sometimes occur.
  • Abnormal pathology, anatomy, tumors and/or malformations that directly and significantly interfere with the normal progression of a procedure.

Also, keep in mind these caveats:

  • Additional time, by itself, does not justify the use of modifier 22.
  • Do not use modifier 22 when the existing CPT® code describes the service.
  • Do not use modifier 22 to indicate that a specialist (no matter how specialized) performed the service.
  • Do not use modifier 22 if the complication is due to the surgeon’s choice of surgical approach.

CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required).” The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort.

Use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: The patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type. Time is also quantifiable (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).

Payors may request a full operative report to verify the unusual nature of the coded procedure. Because most claims are now sent electronically, you should include comments in the narrative field, using everyday language, to explain precisely why (and how much) additional effort and/or time were required to complete the procedure, along with the statement, “Request documentation if needed.” If the payer requests the additional details, be prepared to send the full operative note, along with a cover letter (with provider signature) detailing the unusual nature of the procedure.

The Centers for Medicare & Medicaid Services and other payers scrutinize modifier 22 claims, and primary payor claims submitted with a 22 modifier are often subject to a full medical review. If your claim is correctly coded and well supported by documentation, be persistent in pursuing payment.

Lastly, when submitting your claim with modifier 22, you have to ask for additional payment. Payors won’t automatically increase reimbursement. Instead, you should recommend an appropriate fee. For instance, if a surgical procedure takes twice as long due to unusual clinical circumstances, you could ask the payor to increase the intra-operative portion of the payment by 50 percent. 


Physician Advocate Tip of the Month: Identify Covered California patients who are in months two and three of the Grace Period

July Tip:

Identify Covered California patients who are in months two and three of the Grace Period using the following verification codes:

Plan Name 

Eligibility Code

 Anthem Blue Cross  "Inactive pending investigation"  
 Blue Shield of California   "Pended" 
 Health Net  "Eligibility suspended"

 

What are your options if a patient presents with inactive coverage? Download "Surviving Covered California: Tip Sheet #4" (a member-only resource) at www.cmanet.org/exchange.

Would you like a FREE Practice Assessment?

Find opportunities to increase revenue with the billing process, accounts receivable and collections and discuss all of your concerns. Increase efficiency with patient scheduling, appointments and check-in process. Contact Mitzi to schedule your member-only practice assessment.
 
Receiving practice management guidance from Mitzi Young is a FREE OCMA member benefit!
Mitzi Young
Physician Advocate, CMA Center for Economic Services
888.236.0267
myoung@cmanet.org


Physician Advocate Tip of the Month: Give your patients the answers they need about Covered CA

June Tip:

Give your patients the answers they need about the Covered California networks and more.

Download "Frequently Asked Patient Questions about Covered California."

With the recent launch of California's health benefit exchange, Covered California, millions of Californians are now eligible to obtain insurance through this new online marketplace. Understandably, patients have many questions. Download this document to provide answers to the most common patient questions.

Receiving practice management guidance from Mitzi Young is a FREE OCMA member benefit!
 
Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs: 
 
Mitzi Young
Physician Advocate, CMA Center for Economic Services

888.236.0267
myoung@cmanet.org


Physician Advocate Tip of the Month: Request your FREE Covered CA Contract Analysis

May Tip:

Request your FREE in-depth, paragraph-by-paragraph contract analysis of the four insurance payors participating in Covered California!

OCMA contracted with our business partner Tredway Lumsdaine & Doyle, LLP, to do an in-depth analysis of the contracts of the three insurance payors (Blue Cross, Blue Shield and Health Net) that are offering plans through Covered California. OCMA members can receive a FREE copy of this paragraph-by-paragraph analysis to help aid your understanding of these health plan contracts.
 
Contact Mitzi Young at:
888.236.0267
myoung@cmanet.org


Physician Advocate Tip of the Month: Be aware of the off-exchange products that utilize Covered CA plan networks

April Tip:

Be aware of the off-exchange products that utilize Covered CA plan networks.

1. Every plan offered in Covered CA must also be offered outside of Covered CA, using the same network.  If you see these product names on the ID card, it indicates the patient only has access to the Covered CA network. For more information, download "Surviving the Second Month of Covered CA" at www.cmanet.org/ces.

2. To physicians who are currently participating in the Anthem Blue Cross Individual / Covered CA network: Anthem Blue Cross recently notified over 11,000 practices of a contract addendum that will become effective July 1, 2014. For more information, click here.

Receiving practice management guidance from Mitzi Young is a FREE OCMA member benefit!
Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs: 
 
Mitzi Young
Physician Advocate, CMA Center for Economic Services
888.236.0267
myoung@cmanet.org


Physician Advocate Tip of the Month: Verifying your patients' eligibility and benefits

March Tip:

Verifying your patients' eligibility and benefits in 2014 may save your practice thousands of dollars

The beginning of a new year means calendar year deductibles and visit frequency limitations start over. Remember, with open enrollment there may be changes to patients' benefit plans, or they may even be insured through a new payor. Physicians are urged at this time of the year to be diligent in verifying patients' eligibility and benefits to ensure that you will be paid for services rendered.
 
And don't forget that under the ACA, patients receiving premium assistance through federal tax subsidies are given a 90-day grace period in which to pay their portion of the premium. During the first 30 days of the grace period, the plans must pay for services incurred. However, during days 31-90 of the grace period, plans are allowed to suspend the patient's coverage
 
Don't get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit. 

Receiving practice management guidance from Mitzi is a FREE OCMA member benefit!

Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs: 

Mitzi Young
Physician Advocate, CMA Center for Economic Services
888.236.0267
myoung@cmanet.org


Physician Advocate Tip of the Month - What you need to know about "the grace period"

February Tip:
What You Need to Know About "The Grace Period"

 Federal law allows Covered CA enrollees who receive financial subsidies to keep their health insurance for three months, even if they have stopped paying their premiums. This is known as the "grace period."

CMA made significant progress through their advocacy efforts to help ensure that physicians are not on the hook for unpaid claims in months two and three of the three-month grace period. Instead, coverage will be suspended during those two months. CMA has prepared an easy-to-understand fact sheet to help physicians and their staff understand what the grace period means for their practices and their patients. Click here to download a copy of the grace period fact sheet.

 Upcoming: OCMA Exchange Seminar  

Mitzi Young, OCMA/CMA Physician Advocate, will be hosting an exchange seminar at OCMA on Thursday, February 27. The seminar will focus on how the California health benefit exchange will affect physician practices. Attendance for this seminar is free for OCMA members. For more information and to RSVP, visit https://caexchange.eventbrite.com.


Receiving practice management guidance from Mitzi is a FREE OCMA member benefit!


Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs:

Mitzi Young
Physician Advocate, CMA Center for Economic Services
888.236.0267
myoung@cmanet.org


Physician Advocate Tip of the Month - Don't miss out on your ACA Medi-Cal Payment Increase!

December Tip

Don't miss out on your ACA Medi-Cal Payment Increase!

Attesting is easy, so visit www.medi-cal.ca.gov and complete the ACA Self Attestation Form before 12/31/2013. Physicians must attest individually. Checks are currently being distributed to those who have attested!

Medi-Cal Resource:

Over the past year, there have been a number of changes for Medi-Cal patients and for the physicians who treat them with more to come in 2014. Be sure to review CMA's new Medi-Cal Survival Toolkit available for free at www.cmanet.org/ces (members only).

BONUS TIP:

The deadline to avoid a 1.5% fee schedule penalty in 2015 is fast approaching. There is still time to report at least one valid individual measure via claims for dates of service in 2013. There are many measures that only need to be reported once per reporting period (January 1 through December 31, 2013) that meet the requirement.  
 
The 2013 Physician Quality Reporting System (PQRS) Implementation Guide is a good place to start to identify any measure that might pertain to your practice. The 2013 PQRS Individual Claims Registry Measure Specification Supporting Documents provides the specifications that must be met in order to report the measure (frequency of reporting, procedure codes, diagnosis codes, and reporting measure code(s)). Remember, you cannot go back and add a measure code to claims already submitted.

Receiving practice management guidance from Mitzi is a FREE OCMA member benefit!
 
Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs: 
 
Mitzi Young
Physician Advocate, CMA Center for Economic Services
888.236.0267
myoung@cmanet.org


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