Clean Claims

Posted on May 2, 2019

What is a clean claim? 

A clean claim is a claim that was accurately processed and paid the first time it was submitted to the insurance payer; it is the ultimate goal in medical billing.

Why do you want clean claims?

When a claim is rejected, it delays your payment, inflates your accounts receivable, and increase your operational costs because the whole claim cycle must begin again.  Your staff or billing company will have to identify/review the denials and perform any necessary corrections, in order to resubmit these claims to the payers.  Thus, it is in your best interest to ensure that you have a high percentage of clean claims.


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Should You Have a Compliance Hotline?

Posted on April 1, 2019

Do you provide a Compliance Hotline to your employees, vendors, patients and their families?  One of the seven elements of an effective compliance plan is the development of effective lines of communication.  As a provider, your staff, patients, and family members of your patients need to feel that they have the freedom, as well as the obligation, to report compliance issues, such as potential improper coding or billing practices, vendor misconduct, harassment, bullying, or other improper conduct.  Offering a compliance hotline gives the complainant the ability to report the issues anonymously, a solution for those who are in fear of retaliation.


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Supervision Rules in Radiology

Posted on March 12, 2019

Diagnostic tests paid under the Medicare Physician Fee Schedule (MPFS) for the physician office and the Outpatient Prospective Payment System (OPPS) for hospital outpatient departments are regulated by the Centers for Medicare & Medicaid Services (CMS) by way of its supervision rules.  A supervising physician provides oversight of the medical (technical) components of the facility.  Duties include overseeing quality assurance, testing of equipment, development of protocols for the studies, creating policies and procedures that guide the medical operations of the organization, as well as the oversight of the healthcare staff.  The objective is to ensure study quality and patient safety.


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The Seven Elements of an Effective Compliance Plan

Posted on February 26, 2019

As a healthcare provider, do you have a compliance plan in place?  Healthcare providers and business associates are required by law to have a compliance program.  And as a part of the program, we are mandated to have a compliance plan.  Unfortunately, there is not a “one-size- fits-all” template that providers are able to adopt.  Each organization is different, with different operational environments and ways of doing things.  Due to this uniqueness, it makes sense that each compliance plan would differ from one to another.

While the process of creating a compliance program can be daunting, having one is advantageous.  First, it is a proactive way to ensure that you are meeting the statutory and regulatory requirements.  Second, it shows the government your good faith effort to comply with the law should you ever become the subject of an investigation.  Along with that, should you ever become convicted for violations of any of these statutes and/or regulations, having a compliance plan is favorably considered at sentencing.


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Are You Submitting the Charges for Your Services Compliantly?

Posted on February 1, 2019

Are you submitting your charges correctly and accurately to Medicare and other insurance carriers?  It is imperative that providers code their services correctly and appropriately to prevent violations of the False Claims Act (FCA).  You are violating the FCA when you knowingly submit a false claim to the government or cause another to submit a false claim to the government or knowingly make a false record or statement to get a false claim paid by the government.  Here are some illegal methods that you should avoid when submitting your charges.


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Medicare Fraud & Abuse

Posted on January 16, 2019

How does Medicare define fraud?  It is when you knowingly submit or cause to be submitted false claims or making misrepresentations of facts to obtain a payment from the federal government, which you are not entitled to.  It is also when you knowingly solicit, receive, offer, and/or paying remuneration to induce or reward referrals for items or services that are reimbursable by federal healthcare programs.  Furthermore, it is when you are making prohibited referrals for certain designated services.

 


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Advance Beneficiary Notice (ABN)

Posted on January 3, 2019

Form CMS-R-131 or Advance Beneficiary Notice (ABN) is a written notice that is given to Medicare beneficiaries when item(s) or service(s) is/are expected to not get paid for certain reasons, such as lack of medical necessity.  Providers (including independent laboratories, physicians, practitioners and suppliers) are required to give a beneficiary this notice when payment is expected to be denied by Medicare.

 


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10 Ways to Increase Revenue from Your Patients

Posted on November 27, 2018

Are you satisfied with your collections from your patients? Would your practice benefit from more revenue from your patients? With more patients having higher co-pays and deductible amounts, it is imperative that providers find effective ways to collect amounts that are assigned to patients. The increase in this revenue is crucial to your practice’s vitality.

 


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Routine Waivers of Copays and Deductibles Amounts

Posted on October 15, 2018

While the occasional waiver of co-payment obligations is permissible, the routine waiver of co-pay and deductible amounts is not. The federal Anti-Kickback Statute (AKS) prohibits the remuneration to a beneficiary of a federal and state health plans by any person or entity if the person or entity knows (or should know) that the remuneration is likely to influence the beneficiary to obtain services/items from that particular person/entity.

 


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Qualified Medicare Beneficiary (QMB) Program

Posted on October 8, 2018

Qualified Medicare Beneficiaries (QMBs) are dual-eligible beneficiaries with low income (at or below $12,000); they are individuals who have Medicare and are also enrolled with Medicaid, and get help with their Medicare premiums and cost-sharing. Medicare providers may not charge QMBs for Medicare cost-sharing for any Part A and B covered items and services. This applies to all original Medicare and Medicare Advantage providers and suppliers. The providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. Most states do limit their payments of Medicare deductibles, co-insurance, and co-pays for QMBs. Nevertheless, QMBs have no legal liability to pay Medicare/Medicare Advantage providers their cost-sharing amounts. Therefore, all original and Medicare Advantage providers, even those who don’t accept Medicaid, are not allowed to balance bill QMBs.


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