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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Medical Credentialing Specialists Streamline the Application Process and Prevent Errors

Posted on September 14, 2018

In our years in the medical billing industry, we’ve seen how credentialing can become a major problem area for our clients. We have one client whose new physician started seeing patients before being credentialed and approved by the payers — his services ended up being free — it was bad news all around. The practice lost money and the physician lost production compensation.

Practitioners sometimes get (understandably) overwhelmed by the credentialing process, or find out after completing their initial submission that their approval just isn’t coming as fast as they need. To avoid a protracted approval process or a denial, it is important to understand the complexity of submitting a successful credentialing application, and consider letting a credentialing professional handle the job — it will save you time and money, and let you keep taking care of the patients who need you instead of worrying about reimbursement.

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Moving Payment Up-Front: How to Optimize Point-of-Service Revenue Collection

Posted on August 17, 2018

“Would you consider bringing your car in for an extensive repair job that takes highly skilled mechanics several hours, and then drive your car away without paying?”

Of course not. None of us would. We have heard this and similar analogies from our clients and colleagues when lamenting all the revenue hits the practices are taking due to patient payment-related bad debt. The healthcare industry spends more than $400 billion annually on payments, billing, claims processing, revenue cycle management, bad debt, and collections. As patients’ out-of-pocket expenses continue to balloon, and high-deductible health plans (HDHP) become increasingly common, healthcare organizations must find a method of collecting more from patients.1

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Closing the Loop: Overcoming Patient Payment Obstacles for Revenue Cycle Optimization

Posted on July 13, 2018

For our clients who are staring down huge amounts of bad debt related to services their patients haven’t paid for, the trend toward much higher patient payment responsibility can mean a hot-and-cold relationship with patients.

It’s possible this stems from a disconnect on both sides of the equation: Many patients don’t understand that they are now responsible for paying for more of their healthcare services, and some practices have not yet optimized their processes to make patient payment easy and efficient.

The world has shifted for many of our clients and healthcare organizations of all type and sizes. According to the Medical Group Management Association’s (MGMA) research in 2010, $1 in every $4 of payments comes from patients, and that trend has only continued and intensified since then.1

The patient wields unprecedented power and responsibility in the new healthcare terrain, and many healthcare organizations aren’t doing enough to facilitate better patient relationships and smoother patient payments, which is directly impacting revenue.

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What Is a “Good” Revenue Cycle? Evaluating the Health of Your Practice’s Finances

Posted on May 16, 2018

Two common questions we field from clients are: “So how do we know when we’re done optimizing? When do we know our revenue cycle is good to go?”

These are the billion-dollar questions. Similar to a patient with an ongoing condition asking, “When will I be cured?” the answer is always going to be, “Well, that depends on a lot of factors.” That is where we come in.

Revenue cycle optimization is not a one-size-fits-all prospect. Nor is it a process with a discrete start and end date. Think of it as a living organism, affected by any number of variables that can shift from year-to-year, week-to-week, even hour-to-hour. Revenue cycle management isn’t a “build-it-and-leave-it” task. You must shepherd this complex organism through the life of your organization and keep it as healthy as possible.

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