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The FIRM provides professional claims billing services for individual providers, clinics and facilities. We service all disciplines of practice, i.e., medical, dental, diagnostic testing, chiropractic, physical therapy, optometry/ophthalmology, mental health, chemical dependency, and durable medical equipment.

We offer specialty services such as consultation, collections and appeals, contracting and credentialing, verification and preauthorization and personal injury settlement negotiating. We offer form development and revision services, office reorganization and personnel training.

We have extensive experience in all areas of commercial insurance, Workers Compensation, personal injury, Third Party Administrators, Medicare, Medicaid, and other state and federally funded programs. We offer personalized services designed specifically to meet your needs.

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A Little-Known Windfall for Some Hospitals, Now Facing Big Cuts

New York Times - By Austin Frakt- Aug. 29, 2018 A program meant to help the poor has grown beyond its original intent. Most hospitals are nonprofit and justify their exemption from taxation with community service and charity care. But the Trump administration could require some of them to do more to help the poor, and the hospitals that are in the cross-hairs are those benefiting from an obscure drug discount program known as 340B. The 340B program requires pharmaceutical manufacturers to sell drugs at steep discounts to certain hospitals serving larger proportions of low-income and vulnerable people, such as children or cancer patients. The participating hospitals may charge insurers and public programs like Medicare and Medicaid more for those drugs than they paid for them and keep the difference. By one estimate, the program saved hospitals $6 billion in 2015 alone. The original intent of the program, enacted in 1992, was for hospitals to use the revenue to provide more low-income patients a broader range of services. Many institutions that serve mostly low-income and uninsured populations say they need the program. “Most nonprofit hospitals have very slim profit margins, and they’ve come to rely on this revenue,” said Melinda Buntin, chairwoman of the Department of Health Policy at Vanderbilt School of Medicine. A hospital lobbying group said that for some rural hospitals, the funding cut “could actually be the difference between staying open and closing.” But there is concern that 340B has come to include hospitals that don’t need the extra help and are not using its windfall as originally intended. The program has grown considerably, most recently as a result of an expansion included in the Affordable Care Act. As of 2004, about 200 [...]

How Walmart Outflanks Amazon To Win Seniors In Medicare Advantage Plans

Forbes -Bruce Japsen- Contributor - Aug 21, 2018, 08:09 am Walmart is establishing closer ties with seniors covered by Medicare Advantage plans, an increasingly popular health plan choice for millions of U.S. seniors and where Amazon isn’t yet a player. The latest example of Walmart’s interest in the MA market came this week with the announcement of a program with Anthem, operator of Blue Cross and Blue Shield plans in 14 states. Effective in January 2019, Anthem’s Medicare Advantage plan enrollees can use the insurer’s “over-the-counter plan allowances” to buy OTC medications and personal healthcare items like “first aid supplies, support braces and pain relievers.” Medicare Advantage plans tend to offer cheaper medical care and related healthcare products than someone would pay a retailer or out-of-pocket. Seniors will also be inundated with information from the health plan about products and services from Walmart, which operates more than 4,700 stores and the walmart.com website. “For Walmart, the partnership extends its move upstream to influence where drugs and medical supplies are purchased,” L.E.K Consulting’s Andrew Kadar said of the retailer's program with Anthem. “Roughly 40% of OTC drugs are used by people older than 65 years of age (and) 35% of those seniors are currently enrolled in a Medicare Advantage plan and another 42% have a stand-alone Medicare Part D plan.” The MA market is growing rapidly with more than 10,000 U.S. baby boomers turning 65 every day to become eligible for Medicare. And increasingly, at least one in three are picking an MA plan, analysts say.Currently, just under 35% of Medicare beneficiaries, or about 20 million Americans, are enrolled in MA plans . But MA enrollment is projected to rise to 38 million or 50% market penetration by [...]

Alphabet’s $375 million investment in Oscar Health will expand insurer into Medicare Advantage

HEALTHCARE FINANCE- Susan Morse - AUGUST 14, 2018 Oscar says it uses technology to lower cost: More than 60 percent of member interactions with health systems are virtual. Alphabet's $375 million investment in Oscar Health will expand insurer into Medicare Advantage Oscar says it uses technology to lower cost: More than 60 percent of member interactions with health systems are virtual. Susan Morse, Senior Editor Alphabet, the parent company of Google, is investing $375 million in Oscar Health, the technology-driven health insurer cofounded by Mario Schlosser and Joshua Kushner, brother of White House advisor Jared Kushner. The funds will help move the New York City-based insurer into its next phase of expansion, entering the Medicare Advantage market. "Today, we are announcing Alphabet's plans to invest $375 million into Oscar Health," said Mario Schlosser, co-founder and CEO of Oscar Health. "Oscar will accelerate the pursuit of its mission: to make our healthcare system work for consumers. We will continue to build a member experience that lowers costs and improves care, and to bring Oscar to more people -- deepening our expansion into the individual and small business markets while entering a new business segment, Medicare Advantage, in 2020." Schlosser also announced the addition of Salar Kamangar to Oscar's board. Kamangar is a senior executive at Google and former CEO of YouTube. This is the second big investment for Oscar Health in less than a year. In March, Oscar raised $165 million from Alphabet, Founders Fund and other sources. Numerous insurers have jumped into the MA market, finding there a growing population of aging baby boomers who are attracted to the plan's additional benefits, such as dental and vision. About a third of Medicare beneficiaries have Medicare Advantage [...]

By |August 16th, 2018|Blog, doctor, doctor Credentialing, Healthcare Professionals, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off on Alphabet’s $375 million investment in Oscar Health will expand insurer into Medicare Advantage

CMS is allowing Medicare Advantage plans to cross negotiate Part B and D drug prices

Healthcare Finance - Susan Morse, Senior Editor - August 07, 2018 Starting in 2019, insurers may use step therapy to choose the least expensive drug first before moving on to another prescription. For the first time, Medicare Advantage plans that also offer a Part D benefit have the option of cross negotiating for Part B drugs to get the lowest price, the Centers for Medicare and Medicaid Services told MA organizations in a memo that went out today. Until now, Part B outpatient drugs and Medicare Part D drugs usually picked up at the pharmacy, have been kept separate. Part B drugs often have a competitor in Part D, but plans were not allowed to choose, according to CMS Administrator Seema Verma. Starting in 2019, MA plans that also offer a Part D benefit will be able to cross manage across B and D. In this way, competition is increased for the lower price, Verma said. It might help plans negotiate better discounts and direct patients to high value medications, she said. Part B drugs constitute around $12 billion per year in spending by plans. "As a result of the agency's action today, the Medicare Advantage plans that choose to offer this option will be able to have medicines in Part B compete on a level playing field with those in Part D," CMS said. The new guidance also allows plans to use step therapy, a practice banned in 2012. Step therapy gives the private sector MA plans the option of offering patients a preferred therapy first before moving on to another drug. It is a type of preauthorization for drugs that begins with the most preferred - which is often the least expensive therapy - [...]

CMS Proposes New Reimbursement Cuts for 2019 Medicare OPPS –

LEXOLOGY- Vorys Sater Seymour and Pease LLP- AUGUST 01,2018 On July 31, 2018, the Centers for Medicare and Medicaid Services (CMS) published its proposed changes to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year 2019. A primary goal of the proposed rule (available here) is to eliminate financial incentives for providers to furnish services in a certain location when it is not medically necessary to do so. Practically speaking, this “site neutrality” objective generally translates into reimbursement cuts for provider-based outpatient departments and increases for ASCs. For example, although CMS proposes to update OPPS payment rates by 1.25%, the agency projects that this increase will be largely offset by another noteworthy provision of the proposed rule: the shift of reimbursement for clinic visits at excepted provider-based outpatient departments from the OPPS to the Medicare Physician Fee Schedule (PFS). By way of background, CMS’ 2014 OPPS update required that providers bill all outpatient clinic visits using Healthcare Common Procedure Coding System (HCPCS) code G0463, now the most common service billed under the OPPS. Additionally, section 603 of the Bipartisan Budget Act of 2015 provided that, effective January 1, 2017, providers would no longer be reimbursed for items and services furnished at “non-excepted” outpatient departments under the OPPS, but would instead receive payment under the PFS. Significantly, the PFS is subject to a “relativity adjuster,” meaning that payment rates are scaled downward to a percentage designated by CMS. For 2018, the PFS relativity adjuster is 40%. “Excepted” outpatient departments (who remained eligible for payment under the OPPS) were those that (1) were located within 250 yards of the provider’s main buildings or one of its remote [...]

By |August 2nd, 2018|Blog, Commercial Insurance, doctor, doctor Credentialing, Medicaid, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off on CMS Proposes New Reimbursement Cuts for 2019 Medicare OPPS –