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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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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 –

CMS Proposes Site-Neutral Payments, Drug Price Negotiation

HealthPayer Intelligence- Thomas Beaton- July 26,2018 A proposed rule from CMS aims to expand the use of site-neutral payments, and drug price negotiation at the federal level, to reduce Medicare costs. CMS has proposed a rule that would expand the use of site-neutral payments and improve the drug price negotiation process with manufacturers in order to reduce Medicare’s overall spending. The new rule would allow Medicare to reimburse providers with site-neutral payments for clinic visits, such as check-ups. CMS explained that clinic visits contribute significantly to preventable spending, because many providers charge varying rates for clinic visits. By using site-neutral payments, CMS expects to control spending and reduce clinic costs for beneficiaries. The new payments would lower the cost of clinic visits from $116 with a $23 beneficiary copay down to $46 and a copay of $9. “If finalized, this proposal is projected to save patients about $150 million in lower copayments for clinic visits provided at an off-campus hospital outpatient department,” the agency said in a press release. “CMS is also proposing to close a potential loophole through which providers are billing patients more for visits in hospital outpatient departments when they create new service lines.” By 2019, CMS also expects to reduce hospital outpatient spending by $760 million through the use of site-neutral payments within the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. CMS is adjusting provider payment rates within both programs to promote site neutrality between ASCs and hospital settings. The rule also contains a request for information (RFI) about how to improve the competitive acquisition program (CAP), so CMS can negotiate prescription drug prices with greater authority. CMS is seeking comments about how to innovate [...]

CMS Plugs Changes to E/M Coding

by Shannon Firth, Washington Correspondent, MedPage Today- July 18, 2018 Agency argues that streamlined billing codes will reduce physician burden WASHINGTON -- Administration officials sought to explain the nuts and bolts of proposed changes to evaluation and management (E/M) codes during an online panel discussion on Wednesday. Last week, the Centers for Medicare and Medicaid Services (CMS) proposed several major changes to the Medicare physician fee schedule that the agency believes will greatly reduce some of the paperwork burden physicians face each day. By making documentation less onerous, CMS says it's giving physicians more time to focus on their patients and to improve their health outcomes. "If we're serious about improving the quality and access for patients we have to address the concerns of providers on the front lines," CMS Administrator Seema Verma said during Wednesday's webcast. Under the current system of E/M billing, providers must choose between category levels 1-5. Level 1 is reserved for non-physician services and level 5 is reserved for the most complex patients. "The differences between levels 2 to 5 are often really difficult to discern and time-consuming to document," said Kate Goodrich, MD, CMS's chief medical officer. Physicians are required to justify the level they choose by performing certain tasks, for example reviewing a certain number of organ systems during their physical exam, for level 3 and a different number for level 5, she explained. Also, under current E/M codes, each physician has to redocument a patient's past medical history, family history and social history even if the same histories were already taken and recorded by a previous provider, or during a previous visit. Under the new proposed rule, the agency "collapsed" the codes between 2 and 5, Goodrich said. [...]

CMA News – Coding Corner : Modifier 59

California Medical Association News - Coding Corner: Modifier 59 -May 01, 2018 | Practice Management CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care. Modifier 59 Distinct procedural service is an “unbundling modifier.” When properly applied, it allows you to separately report—and to be reimbursed for—two or more procedures that normally would not be billed or paid independently during the same provider/patient encounter. For example, per CPT Assistant (Jan. 2018): Code 20680 [Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)] describes a unit of service that is typically reported only once, provided the original injury is located at only one anatomic site, regardless of the number of screws, plates, or rods inserted, or the number of incisions required for removal. The removal of a single implant system or construct, which may require multiple incisions (eg, intramedullary [IM] nail and several locking screws) is reported only once with code 20680. Reporting code 20680 more than once is appropriate only when the hardware removal is performed for another fracture(s) in a different anatomical site(s) unrelated to the first fracture (eg, ankle hardware and wrist hardware). In these circumstances, modifier 59, Distinct Procedural Service, would be appended to subsequent uses of the implant removal code. CPT® and CCI Conditions to Append Modifier 59 As outlined in the CPT® codebook, the general conditions under which you might append modifier 59 include situations where two or more CPT® codes, not normally reported together, are performed at a: Different session Different procedure or surgery [...]

Legal Compliance: One More Reason to Collect Patient Deductibles and Copays

WEBPT - By Tom Ambury - June 24, 2018 Collecting coinsurance, copays, and deductibles upfront is an important piece of the effort to accurately value the services we provide. And yet, we still hear about practices that routinely waive their patients’ deductibles and copays. Today, I’ll discuss another reason not to routinely waive deductibles and copays. In the past, I’ve written about collecting deductibles and copays when a patient presents with a federally funded insurance like Medicare. In cases involving the Department of Justice, the powers that be have stated very clearly that the practice of routinely waiving deductibles and copays can be a violation of the Federal Anti-Kickback Statute. But what about commercial insurances like BlueCross BlueShield, Aetna, and Cigna? That’s what I’ll chat about today. Why You Shouldn’t Waive Before I get into the compliance-related reasons to collect full payment for our services, let me say that to me, from a business standpoint—and with the knowledge that payments are continually being reduced as the cost of doing business keeps rising—it’s hard to imagine why a provider wouldn’t want to collect full payment for his or her services. Here’s an example I came up with to better explain my point: Let’s say you’re getting paid $75 per visit from a commercial insurance company, with $25 of that total coming from the patient’s copay and $50 from the insurance company. (These totals don’t necessarily reflect what’s happening in the real world; for illustration purposes, we’re staying in Tom’s World.) Wouldn’t you rather get paid $75 per visit versus waiving the copay and accepting only $50? Aren’t your services worth the full $75—if not more? And if the business reasons are not enough to sway you toward collecting [...]

Tech company once lauded for growth shutters Tampa office suddenly, leaves over 100 without jobs

By Janelle Irwin – Reporter, Tampa Bay Business Journal-Jun 21, 2018, 6:55pm EDT Updated Jun 22, 2018, 12:47pm Health care technology firm CareSync closed its doors on Thursday despite previously announced plans to hire 350 people by the end of 2017 and expand its Tampa headquarters. A manager with the company, who spoke on the condition of anonymity, told the Tampa Bay Business Journal that there had been several rounds of layoffs in recent weeks, but that a plan to sell the company gave remaining employees hope their jobs would remain intact. The employee said a deal fell through and the company had been “bleeding money” the past several weeks. The company's Twitter and Facebook pages were both taken down Thursday evening. Employees at the Tampa and Hardee County offices were told Thursday to pack up their things and leave and that the business was closing permanently. The employee said the company was not offering COBRA benefits to employees and that existing health coverage would be terminated immediately. Employees were also not offered severance. “It really saddens me and most of us because we were blindsided,” Kathy Clem, who identified as an employee, lamented on Facebook. “Someone was supposed to buy the company, but it fell through." Multiple sources said the closure was the result of a buyout by internet-based grocery delivery company Shipt falling through. A request for comment from Shipt was not immediately returned. In December 2017, Target Corp. acquired Shipt. (Update: Shipt CEO Bill Smith was personally going to buy CareSync. Read more here.) In 2014, CareSync moved into 51,000 square feet at 14055 Riveredge Drive in the Hidden River Corporate Park, and brought with it 150 jobs, planning to reach a [...]

By |June 28th, 2018|Blog, Commercial Insurance, Doctor, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physical Therapy, Physician Credentialing|Comments Off on Tech company once lauded for growth shutters Tampa office suddenly, leaves over 100 without jobs

House GOP plan would cut Medicare, Medicaid to balance budget

Washington Post -  Erica Werner -June 19 at 4:48 PM House Republicans released a proposal Tuesday that would balance the budget in nine years — but only by making large cuts to entitlement programs, including Medicare, that President Trump vowed not to touch. The House Budget Committee is aiming to pass the blueprint this week, but that may be as far as it goes this midterm election year. It is not clear that GOP leaders will put the document on the House floor for a vote, and even if it were to pass the House, the budget would have little impact on actual spending levels. Nonetheless the budget serves as an expression of Republicans’ priorities at a time of rapidly rising deficits and debt. Although the nation’s growing indebtedness has been exacerbated by the GOP’s own policy decisions — including the new tax law, which most analyses say will add at least $1 trillion to the debt — Republicans on the Budget Committee said they felt a responsibility to put the nation on a sounder fiscal trajectory. “The time is now for our Congress to step up and confront the biggest challenge to our society,” said House Budget Chairman Steve Womack (R-Ark.). “There is not a bigger enemy on the domestic side than the debt and deficits.” The Republican budget confronts this enemy by taking a whack at entitlement spending. Lawmakers of both parties agree that spending that is not subject to Congress’s annual appropriations process is becoming unsustainable. But Trump has largely taken it off the table by refusing to touch Medicare or Social Security, and Democrats have little interest in addressing it except as part of a larger deal including tax increases — [...]

New Medicare Advantage rules hold big potential for pop health

Healthcare Dive- Meg Bryant- June 13, 2018 The push toward valued-based care and population health management has raised visibility around nonmedical conditions that impact health outcomes. Improving health outcomes using population health strategies could get a major boost with a new Medicare Advantage rule taking effect this week. Payers will now be able to work with companies like Uber or Lyft to provide transportation, for example, as part of a more complete set of benefits for the quickly growing MA population. CMS issued a final rule in May giving MA plans more flexibility in determining the types of supplemental benefits they can offer chronically ill enrollees, including nonmedical benefits. The new policy, part of a broad 2019 Medicare payment rule, means plans like UnitedHealthcare and Humana aren't harnessed to a set palette of supplemental benefits for members with chronic conditions, but can tailor them to the specific needs of individuals. The rule could see an array of new benefits aimed at improving health outcomes by addressing issues such as housing and food insecurity, transportation and social isolation. Potential benefits include ride-hailing services, home visits, nutritional support, air conditioners for people with asthma, home renovations like grab bars and other accommodations to prevent falls, and home health aides. Providers have praised the expansion of benefits. “We now have a funding stream effectively within Medicare Advantage around social services,” Don Crane, president and CEO of America’s Physician Groups (APG), told Healthcare Dive in an interview. He called the change a “necessary and appropriate step” in managing chronic diseases. The focus on social determinants of health and population health management is part of the broader shift to value-based care and reimbursement. Some providers, payers and employers already offer wellness and prevention programs or [...]