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.


Noridian incorrectly denies 300,000 claims for E&M services

Last fall, the Centers for Medicare and Medicaid Services (CMS) experienced some editing issues with new patient E&M codes that resulted in incorrect claim denials. These problems started in October 2013, and was thought to have been corrected in late January 2014. The California Medical Association recently learned, however, that some claims continued to be paid incorrectly through July 15, 2014.
 
Noridian, California's Medicare contractor, in January began making mass adjustments and correcting claims subjected to overpayment recovery. Unfortunately, while implementing the corrections, Noridian inadvertently subjected established patient E&M codes to incorrect editing, resulting in incorrect denial of codes 99211- 99215.
 
Noridian has corrected the editing for both the new patient codes and the established patient codes, and claims received by Noridian on and after July 16, 2014, should be processing correctly. Noridian is now beginning the process of mass adjustments to the incorrectly denied claims. Due to the number of claims involved (~300,000 claims back to October of 2013), this process could take a month or so to complete.
 
Physicians do not need to do anything to have their claims adjusted and they should NOT resubmit the claims. The claims will be automatically adjusted.
 
For more information, see Noridian's notice on this issue.
 
Contact: Mitzi Young, OCMA Physician Advocate (888) 236-0267 or myoung@cmanet.org.

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


IMQ Expands Peer Review Services

Does your medical staff need help with peer review? The Institute for Medical Quality is expanding its services to include Clinical Case Review of individual cases and Judicial Review services in addition to our existing Comprehensive Peer Review services.
 

Through off-site patient chart review, an IMQ Clinical Case Review consultation provides an objective evaluation of the clinical practice of one or more physician members of a hospital medical staff, physician group, or ambulatory care practice through peer review of selected cases. IMQ's involvement is especially helpful when an organization will benefit from expert review of one or more patient cases, but needs physicians of the appropriate specialty who have no real or perceived conflicts of interest.

Additionally, IMQ is seeking physicians to support this expansion of services. For more information about any of IMQ’s peer review services, or about becoming a physician reviewer, please contact Julie Hopkins at 415-882-5165 or jhopkins@imq.org


Orange County Medical Association Selects Acentec, Inc. as Business Partner

National healthcare technology firm will extend special offers on HIPAA compliance to OCMA Physician Members

Irvine, Calif., May 20, 2014 - The Orange County Medical Association is pleased to announce another benefit of membership.  The OCMA has designated Acentec, Inc. as its Business Partner for physicians seeking cost effective and complete HIPAA compliance and IT management. 
 
Acentec has agreed to offer OCMA members discounts up to 20% for HIPAA compliance and IT management needs.
 
"We're pleased to offer OCMA members the security and protection of our  HIPAA compliance and healthcare IT services," said Jeff Mongelli, CEO of Acentec, Inc. "New HIPAA requirements and increased penalties make the proper care and handling of sensitive patient health information essential for every provider and medical organization. We share in the common goal of OCMA members of keeping private information secure so our community can benefit from the authorized access of those who need it."
 
The following Acentec services are included in our relationship with OCMA members: discounted HIPAA compliance services including annual risk assessments, documentation, and employee training; IT services including network and systems management and monitoring, HIPAA compliant remote back-up and hosting, secure email & messaging, business disaster recovery that eliminates or minimizes downtime and data loss, and 24/7 access to our support staff.
 
 Acentec's corporate offices are located in Irvine, CA and they have staff  located nationwide.
 
About Acentec, Inc.
Southern California-based Acentec, Inc. provides a full range of healthcare IT services to medical practices nationwide. Our services include medical billing, IT management and support, EMR software support, HIPAA compliance, and a certified patient portal. For more information, visit http://www.acentec.com.
 

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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


Orange County Medical Association Selects Argus Medical Management as Preferred Business Partner

Irvine, Calif. March 24, 2014.   The Orange County Medical Association is pleased to announce another benefit of membership.  The OCMA has designated Argus Medical Management as its Business Partner for physicians seeking practice management services.

 

OCMA members will receive the following benefits:

 

  • Free membership in GroupSource, a Physician Group Purchasing Organization
  • 10% discounts the first year and 5% discounts the second year on Argus' services
  • Physicians who join Argus' Integrated (Independent)Physician Medical Group  model will receive free OCMA membership

Argus Medical Management offers the following physician practice management services:

 

  • Accounting, Regional Manager Oversight
  • Billing, EMR, HIE, Billing & Practice Management Systems
  • Credentialing, Purchasing Discounts, Contracting
  • Integrated physician medical group model which stresses physician independence
  • Marketing
  • PC Support
  • Staff Administration (payroll, benefits, H.R.)   

Argus Medical Management has provided a full spectrum of practice management services to physicians in Orange & Los Angeles Counties since 1995.

 

Contact:  Shing Huang, CFO, 562-299-5210, SHuang@ArgusMSO.com

For GroupSource (GPO/Purchasing Discounts): Peachy Paulino, Director, Marketing Support, 562-299-5252, PPaulino@ArgusMSO.com

 

Please visit the Argus Medical Management website at www.ArgusMSO.com


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