Request a Quote


Our Services


Summary of Services

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.

­

About kristian

This author has not yet filled in any details.
So far kristian has created 160 blog entries.

Medicare Advantage Data Could Strengthen Outcomes, Spending Research

HCA News- Jared Kaltwasser -MAY 18, 2018 CMS plans to begin releasing Medicare Advantage (MA) data to health researchers, in a move that could substantially improve the quality and robustness of public health analysis. “We recognize that the MA data is not perfect, but we have determined that the quality of the available MA data is adequate enough to support research,” CMS Administrator Seema Verma, MPH, said during last month’s announcement. “And although this is our first release, going forward, we plan to make this data available annually.” Gerard Anderson, PhD, a professor at the Bloomberg School of Public Health at Johns Hopkins University, said the data will be an important piece of the puzzle as researchers track health usage, spending, and outcomes. “Many us have been using Medicare fee-for service-data for 30-plus years,” he told Healthcare Analytics News™. “We did not have access to the same data on MA plans, and this made it difficult to determine if the care was better in MA plans than it was in fee for service. It also allows us to compare the mix of services that each program receives.” CMS makes privacy-protected claims data available to researchers through its Virtual Research Data Center (VRDC), which Verma said has information on CMS’ 130 million current enrollees, as well as data from patients who previously were covered by CMS programs. “If you’ve seen a study that references Medicare data, it probably came from an analysis of data in the VRDC,” Verma said. The Medicare Advantage release wasn’t Verma’s only announcement. She said CMS will make additional databases available in the coming years. “Next year, we expect to make Medicaid and Children’s Health Insurance Program data available,” she said. “This means [...]

Trump Promises Lower Drug Prices, but Drops Populist Solutions

NY Times-  By Robert Pear May 11, 2018 WASHINGTON — President Trump vowed on Friday to “bring soaring drug prices back down to earth” by promoting competition among pharmaceutical companies, and he suggested that the government could require drugmakers to disclose prices in their ubiquitous television advertising. But he dropped the popular and populist proposals of his presidential campaign, opting not to have the federal government directly negotiate lower drug prices for Medicare. And he chose not to allow American consumers to import low-cost medicines from abroad. He would instead give private entities more tools to negotiate better deals on behalf of consumers, insurers and employers. Speaking in the sun-splashed Rose Garden of the White House, Mr. Trump said that a “tangled web of special interests” had conspired to keep drug prices high at the expense of American consumers. “Everyone involved in the broken system — the drugmakers, insurance companies, distributors, pharmacy benefit managers and many others — contribute to the problem,” Mr. Trump said. “Government has also been part of the problem because previous leaders turned a blind eye to this incredible abuse. But under this administration we are putting American patients first.” His proposals hardly put a scare into the system he criticized. Ronny Gal, a securities analyst at Sanford C. Bernstein & Company, said the president’s speech was “very, very positive to pharma,” and he added, “We have not seen anything about that speech which should concern investors” in the pharmaceutical industry. Shares of several major drug and biotech companies rose immediately after the speech, as did the stocks of pharmacy benefit managers, the “middlemen” who Mr. Trump said had gotten “very, very rich.” The Nasdaq Biotechnology Index rose 2.7 percent on Friday. [...]

Medicare Advantage Plans Can Pay for Many LTC Services in 2019: Feds

Plans could cover adult day care, respite care and in-home support services. By Allison Bell | May 02, 2018 at 10:27 AM The Centers for Medicare and Medicaid Services is getting ready to let Medicare Advantage plan issuers add major new long-term care benefits to their supplemental benefits menus. The Better Medicare Alliance, a Washington-based coalition for companies and groups with an interest in the Medicare Advantage has posted a copy of a memo that shows CMS is reinterpreting the phrase “primarily health related” when deciding whether a Medicare Advantage plan can cover a specific benefit. Kathryn Coleman, director of the CMS Medicare Drug & Health Plan Contract Administration Group, writes in the memo, which was sent to Medicare Advantage organizations April 27, that CMS will let a plan cover adult day care services for adults who need help with either the basic “activities of daily living,” such as walking or going to the bathroom, or with “instrumental activities of daily living,” such as the ability to cook, clean or shop. A Medicare Advantage plan could not, apparently, cover skilled nursing home care, or assisted living facility fees. But, in addition to adult day care, a Medicare Advantage plan could pay for: In-home support services to help people with disabilities or medical conditions perform activities of daily living and instrumental activities of daily living within the home, “to compensate for physical impairments, ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and health care utilization.” Short-term “respite care” or other support services for family caregivers. Making non-Medicare-covered safety changes, such as installing grab bars, that might help people stay in their homes. Non-emergency transportation to health care services. (Plans can already [...]

Payer Healthcare industry lambastes Trump administration’s short-term health plan proposal

Fierce Healthcare - by Mike Stankiewicz | Apr 24, 2018 1:31pm The health insurance and hospital sectors are nearly unanimous in their opposition to the Trump administration's proposal to expand short-term health plans, citing higher premiums as a major consequence if it moves forward. Such plans have historically been used during a lapse in coverage following a change in employment and limited to just a few months. But the Department of Health and Human Services (HHS) wants to expand short-term plan coverage for up to a year, a move viewed by many as an attempt to undermine the Affordable Care Act (ACA). The plans could skirt key ACA requirements, such as essential health benefits and pre-existing coverage protections. Administration officials contend the extension will give consumers more choice without raising premiums, but some of the industry's biggest players aren't buying it. The healthcare sector remains in flux as policy, regulation, technology and trends shape the market. FierceHealthcare subscribers rely on our suite of newsletters as their must-read source for the latest news, analysis and data impacting their world. Sign up today to get healthcare news and updates delivered to your inbox and read on the go. In comments submitted to HHS (PDF), America's Health Insurance Plans (AHIP) said a year-long duration would move young, healthy people out of the exchanges, increasing premiums for older, sicker people who remain. "At the same time, we are concerned that this proposed rule will lead to more people being uninsured and underinsured, and to higher costs in the long run," Matt Eyles, incoming president and CEO of the trade association, said in a statement. Instead, AHIP recommended the administration extend the duration of short-term plans from 90 days to six [...]

Health Plans Simplify Doctor Credentialing To Boost Medicaid Participation

Forbes -Bruce Japsen , CONTRIBUTOR APR 2, 2018 @ 09:01 AM  Health insurance companies are streamlining credentialing of physicians who contract with Medicaid health plans in hopes of boosting doctor participation in the program that provides care for the poor. A snapshot of new doctor credentialing begins Monday in Texas where the Texas Association of Health Plans and the Texas Medical Association (TMA) are launching a new venture that all 19 Medicaid health plans in the state can use. Participating health plans in the Texas “credentialing and verification organization” include Aetna, Centene, Cigna, UnitedHealth Group and Blue Cross and Blue Shield of Texas. It’s not uncommon for doctors to have to provide background information to confirm they are in good standing for each and every health insurance plan they contract with to provide care for patients. And doctors complain the credentialing process designed to improve patient safety and prevent fraud is actually creating problems that hurt patient access. “Anything that cuts through Medicaid’s tangled web of red tape is good for Texas physicians and good for our patients,” Texas Medical Association President Dr. Carlos Cardenas said. “The centralized credentialing organization should cut away a big knot of Medicaid hassles.” Across the country, physician participation in the Medicaid program varies. About 70% of office-based physicians accept Medicaid, the Kaiser Family Foundation reported last year, but the percentage of physicians accepting “new Medicaid patients varies by state, ranging from 39% in New Jersey to 97% in Nebraska.” In Texas, which didn’t expand Medicaid under the ACA, Medicaid participation is also impacted by reimbursement rates and the doctor shortage. Health plans don't want to see administrative issues like credentialing impacting impacting doctor participation given more than 4 million Medicaid [...]

CMS issues final rule allowing states to pick essential health benefits

Modern Healthcare- By Shelby Livingston and Susannah Luthi | April 9, 2018 The CMS issued a final rule late Monday aimed at giving states and health insurers more flexibility and reducing regulatory burdens in the individual and small group health insurance markets. The final rule allows states to define essential health benefits that individual and small group insurers must offer; gives insurers more options when reporting their medical loss ratios; and eliminates standardized plan options to maximize innovation. In separate guidance also issued today, the CMS said it is expanding hardship exemptions for consumers so that people who live in counties with one or no exchange insurer will be exempt from paying the Affordable Care Act's penalty for not having coverage. Health insurers have anxiously been waiting for the rule, which is usually released in mid-March. It follows on the heels of other actions by the Trump administration aimed at easing Affordable Care Act regulations in the name of promoting consumer choice, including a proposal to extend the duration of short-term medical plans and expanding access to association health plans that don't comply with ACA consumer protections. "Obamacare has serious flaws that ultimately need Congressional action in order to correct, but until the law changes, we won't stand idly by as Americans suffer, and today's announcement will offer some relief to Americans who have seen higher premiums and fewer choices since Obamacare was implemented," CMS Administrator Seema Verma said during a press call on Monday. In the final rule, the CMS kept much of what it proposed in October. The agency went ahead with its earlier proposal to gives states flexibility to determine the essential health benefits that exchange insurers must offer, but pushed the effective [...]

Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries

Kaiser Health News- By Susan Jaffe - APRIL 3, 2018 Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage coverage when new federal rules take effect next year. On Monday, the Centers for Medicare & Medicaid Services (CMS) expanded how it defines the “primarily health-related” benefits that insurers are allowed to include in their Medicare Advantage policies. And insurers would include these extras on top of providing the benefits traditional Medicare offers. “Medicare Advantage beneficiaries will have more supplemental benefits making it easier for them to lead healthier, more independent lives,” said CMS Administrator Seema Verma. Of the 61 million people enrolled in Medicare last year, 20 million have opted for Medicare Advantage, a privately run alternative to the traditional government program. Advantage plans limit members to a network of providers. Similar restrictions may apply to the new benefits. Many Medicare Advantage plans already offer some health benefits not covered by traditional Medicare, such as eyeglasses, hearing aids, dental care and gym memberships. But the new rules, which the industry sought, will expand that significantly to items and services that may not be directly considered medical treatment. CMS said the insurers will be permitted to provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care. Although insurers are still in the early stages of designing their 2019 policies, some companies have ideas about what they might include. In addition to transportation to doctors’ offices or better food options, some health insurance experts said additional benefits could include simple modifications in beneficiaries’ homes, such [...]

Urgent Care Insurance Claims Rise Sharply, Faster than ED

Media Health Leaders- Gregory A. Freeman, March 26, 2018  Insurance claims for urgent care exploded over a nine-year period, rising much faster than claims for emergency care. Private insurance claim lines for urgent care centers grew 1,725% from 2007 to 2016, more than seven times faster than that of emergency room claims, which grew 229% over the same period. The increases are described in analysis by FAIR Health, a nonprofit organization that focuses on transparency in healthcare costs. The analysis used data from FAIR Health's database of over 25 billion privately billed healthcare claims. The report includes trends and patterns in the places where patients receive healthcare, which the group says have undergone dramatic changes in recent years as alternative places of service—including urgent care centers, retail clinics, telehealth and ambulatory surgery centers (ASCs)—have become more widespread. The urgent care center market has reached 15 billion, according to a report by Kalorama Information. Some of the growth is due to hospital systems starting urgent care centers to reduce the demand at their hospital emergency rooms, aiming to make those areas of their system more profitable, the report notes. Other centers are started by entrepreneurial physicians as a means to expand their income while meeting a market need. The number of clinic locations has similarly risen strongly, standing at over 10,000 locations in 2017, according to the Kalorama report. Kalorama estimates that the average urgent care center in 2016 saw 294 patients per week and about 15,300 patients throughout the year. It predicts patient volume will continue to expand through 2021 to about 300 patients per week. Diagnoses Differ by Location Different places of service are associated with different diagnoses, the FAIR Health report notes. For example, [...]

Doctors advocate overhauling some Medicare billing codes

Modern Healthcare- By Virgil Dickson  | March 22, 2018 Lowering documentation standards for a commonly used set of billing codes would lead to better quality of care, doctors told the CMS during a conference call Wednesday. Most physicians bill Medicare for patient visits under a relatively generic set of codes that distinguish the level of complexity and site of care. They are called evaluation and management visit codes. The last significant update to the E/M guidelines was more than 20 years ago. "The agency has heard repeatedly over the years that these documentation guidelines are potentially outdated and need to be revised," Marge Watchorn, deputy director of CMS' Division of Practitioner Services, said during the call which was hosted by the agency to request input from the provider community. The codes were developed with a paper-based system in mind, said Dr. Paul Rudolf, a partner at Arnold & Porter who represents the American Geriatrics Society. Clinicians currently must provide a comprehensive medical history each time they submit a claim. They'd rather document why a patient is receiving care in a specific instance of treatment. "There is now somewhat of a perverse incentive that ordering more tests will meet medical decision-making" standards, said Dr. Thomas Sugarman, an emergency medicine doctor at Sutter Delta Medical Center in California. Requirements around E/M also make it harder to bill for more-intensive office visits for some of the sickest patients. The codes "disincentivize addressing multiple chronic conditions in one visit, which is something we would very much like to do," said Dr. Lindsay Botsford, a family physician at Memorial Hermann Health System in Houston. The CMS first announced its intentions to review E/M guidelines for the 2018 Medicare physician fee schedule rule. Watchorn said [...]

Insurers Gobble Doctor Practices To Bolster Medicare Advantage Plans

Forbes- Bruce Japsen - MAR 12, 2018 @ 08:00 AM News that Centene is buying a large medical group is the latest sign that health insurers are engaged in a doctor-buying binge to compliment their Medicare Advantage businesses by owning group practices that treat a lot of seniors. In Centene’s case, the health insurer is getting a provider of medical care in Community Medical Group that has 15 health centers throughout the Miami-Dade County area of south Florida. Centene last week described Community Medical as a “leading at-risk primary care provider” that serves more than 70,000 patients including those covered by Medicare Advantage. It’s the kind of deal that insurers are scouting across the country. “There will be more acquisitions of primary care groups,” Bill Frack, a managing director in L.E.K Consulting ’s health care services practice said in an interview. “Sophisticated groups are the best way to manage the cost of care in an effective manner. They have the resources to manage complicated cases in a sophisticated way.” To be sure, health plans are on the hunt to buy doctor practices with the staff, technology, information systems and providers to effectively manage the complex care of elderly Medicare beneficiaries, particularly as value-based care takes hold. Practices that provide effective treatment upfront in the doctor’s office leave more of the premium dollar for an insurance company to profit from or share with the providers. The Centene deal surprised some observers given the insurer is better known for administering Medicaid benefits for states and offering individual coverage under the Affordable Care Act. In buying Community Medical, it will get a provider of medical care that has patients insured by all three forms of insurance: Medicaid, Obamacare [...]