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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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So far kristian has created 179 blog entries.

Medicare Advantage organizations overturned 75% of their denials, fed investigation shows

Beckers Hospital CFO Report- Written by Kelly Gooch | October 02, 2018 A recent investigation by the U.S. Office of Inspector General found between 2014 and 2016, Medicare Advantage organizations overturned 75 percent of their preauthorization and payment denials upon appeal. The OIG's report, released in September, found Medicare Advantage organizations overturned about 216,000 denials annually during the period. Investigators also found that independent reviewers overturned more denials at higher Medicare Advantage appeals levels. "The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided," the agency wrote. "This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment.  During 2014-16, beneficiaries and providers appealed only 1 percent of denials to the first level of appeal." In addition to the numbers of overturned denials, persistent performance problems related to Medicare Advantage organizations were identified by CMS audits, according to the OIG. Investigators said one example is CMS citing 56 percent of audited contracts for making inappropriate denials in 2015. They said 45 percent of contracts were also cited for providing incomplete or incorrect information in denial letters. The OIG recommended CMS step up oversight of Medicare Advantage contracts, "including those with extremely high overturn rates and/or low appeal rates and take corrective action as appropriate" and offer beneficiaries easily accessible information about serious violations by Medicare Advantage organizations. CMS agreed with the recommendations. Questions about Medicare, private Medical Insurance and health insurance reimbursement? Physician Credentialing and Revalidation? or other changes in Medicare, Commercial Insurance, and Medicaid billing, credentialing and payments? Call the Firm Services at 512-243-6844

By |October 4th, 2018|Blog, Credentialing, Doctor, doctor, doctor Credentialing, Health Insurance, Healthcare Professionals, ICD-10, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off on Medicare Advantage organizations overturned 75% of their denials, fed investigation shows

Private Medicare Plans Faulted by Watchdog Over Denials of Care

Bloomberg - By John Tozzi- September 26, 2018, 9:01 PM PDT A new federal watchdog report warns that privately run Medicare health plans used by millions of older Americans may be improperly denying patients medical care. Federal auditors have found “widespread and persistent problems related to denials of care and payment in Medicare Advantage,” the privately administered plans that insure more than 20 million people, according to the report from the Health and Human Services Office of Inspector General. Medicare Advantage plans collect a fixed fee from the government for taking care of patients 65 or older who qualify for traditional Medicare coverage. The fixed per-patient rates the government pays may give plans “an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits,” the report said. Medicare Advantage plans have become popular with consumers because they combine traditional Medicare benefits with additional coverage, such as vision, dental care, and prescription drugs. The program paid $210 billion to Medicare Advantage plans last year. Companies including UnitedHealth Group Inc., Humana Inc., and Aetna Inc. are the largest sellers of the coverage. Enrollment in Medicare Advantage has roughly doubled in the past decade, and one-third of Medicare patients are now covered by the private plans. In 2016, Medicare Advantage plans denied 4 percent of requests to approve treatment before it was provided, known as prior authorization, and 8 percent of requests for payment after treatment, according to the report. Only 1 percent of patients disputed the insurers’ denials, but in those cases, the decisions were overturned three-quarters of the time, according to the report. Improper denials “may contribute to physical harm for beneficiaries if they’re not getting access to services that they [...]

New Medicare Advantage tool will lower prices, but also limit choice

Benefits PRO - Susan Jaffe | September 19, 2018 at 11:07 AM Under the new rules, private Medicare insurance plans could require patients to try cheaper drugs before moving on to more expensive options. Starting next year, Medicare Advantage plans will be able to add restrictions on expensive, injectable drugs administered by doctors to treat cancer, rheumatoid arthritis, macular degeneration and other serious diseases. Under the new rules, these private Medicare insurance plans could require patients to try cheaper drugs first. If those are not effective, then the patients could receive the more expensive medication prescribed by their doctors. Related: Government drug price disclosure confirms it: costs are soaring Insurers use such “step therapy” to control drug costs in the employer-based insurance market as well as in Medicare’s stand-alone Part D prescription drug benefit, which generally covers medicine purchased at retail pharmacies or through the mail. The new option allows Advantage plans — an alternative to traditional, government-run Medicare — to extend that cost-control strategy to these physician-administered drugs. In traditional Medicare, which covers 40 million older or disabled adults, those medications given by doctors are covered under Medicare Part B, which includes outpatient services, and step therapy is not allowed. About 20 million people have private Medicare Advantage policies, which include coverage for Part D and Part B medications. Some physicians and patient advocates are concerned that the pursuit of lower Part B drug prices could endanger very sick Medicare Advantage patients if they can’t be treated promptly with the medicine that was their doctor’s first choice. Critics of the new policy, part of the administration’s efforts to fulfill President Donald Trump’s promise to cut drug prices, say it lacks some crucial details, including how [...]

UnitedHealthcare wins court case over Medicare Advantage overpayment rule

Healthcare Finance -Susan Morse Senior Editor - September 10, 2018 Ruling throws out 2014 rule, leading to question of how CMS will determine whether it has overpaid an MA insurer. UnitedHealthcare wins court case over Medicare Advantage overpayment rule Ruling throws out 2014 rule, leading to question of how CMS will determine whether it has overpaid an MA insurer. UnitedHealthcare has won its court case over the way the Centers for Medicare and Medicaid Services calculates whether it has overpaid Medicare Advantage insurers. The U.S. District Court for the District of Columbia on Friday granted UnitedHealth's motion for summary judgement and vacated CMS's 2014 overpayment rule, leading to the question of how CMS will amend the rule to determine whether it has overpaid an MA insurer. CMS could also appeal the ruling. Federal Judge Rosemary Collyer said the 2014 overpayment rule was not equitable to Medicare and Medicare Advantage insurers, which is required by law. One of the issues for insurers is that the current way CMS calculates payment results in the false appearance of better health among Medicare Advantage enrollees compared to traditional Medicare participants, leading to systematic underpayments to MA insurers, according to the ruling. Judge Collyer said the current way CMS calculates payment subjects the insurers to a more searching form of scrutiny than CMS applies to its own enrollee data, resulting in a false appearance of better health among Medicare Advantage beneficiaries. Medicare pays hospitals based on the diagnosis related group, or DRG, at the time of patient discharge. Under Medicare Part B, physicians submit diagnosis codes, but payment depends on the services provided, and not on the way the diagnosis is submitted. In contrast, MA insurers are not paid based [...]

By |September 12th, 2018|Blog, Chiropractic, Doctor, doctor, doctor Credentialing, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physical Therapy, Physician Credentialing, Podiatrist|Comments Off on UnitedHealthcare wins court case over Medicare Advantage overpayment rule

Come out and hear our owner Tia Aspra speak at 11th edition of Larry Laurent’s Chiropractic Law Seminar

Come out and hear our owner Tia Aspra speak at 11th edition of Larry Laurent’s Chiropractic Law Seminar series on Saturday, September 8, 2018. This fall’s event will be held in Austin, at the Granduca Hotel – 320 South Capital of Texas Hwy, Bldg B, Austin, Texas, 78746 from 8:00 a.m. to approximately 5:30 p.m. Ms. Tia Aspra of Financial Investigation & Reimbursement Management and Ms. Kathy Jones of NACA - Texas, will be providing tips on risk management, coding, credentialing, documentation and office compliance practices to ensure that your new practice complies with all state and federal laws, as well as our Board’s regulatory programs. This Chiropractic Law seminar has been approved for 8 hours of CE credit, including the 4 hours of Ethics, Documentation and Jurisprudence required by the Texas Board of Chiropractic Examiners. We have kept the cost low - $198.00 for doctors, $79.00 for staff accompanying a doctor and $98 for CA/staff attending without a doctor. You will have the opportunity to obtain thousands of dollars worth of free legal information, consulting services and information on office procedures for a very low registration fee. To register give Larry Laurent a call at (512) 996-8844 or send an email to (larry@larrylaurent.com) if you have any questions. We hope to see you in Austin on Saturday, September 8, 2018.

By |September 4th, 2018|Chiropractic, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, Medical, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Multi-Specialty, Obamacare, Physician Credentialing, Specialties, Staff Training|Comments Off on Come out and hear our owner Tia Aspra speak at 11th edition of Larry Laurent’s Chiropractic Law Seminar

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 –