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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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CMS Finalizes Changes to Advance Innovation, Restore Focus on Patients

cms.gov- November 01,2018 CMS Finalizes Changes to Advance Innovation, Restore Focus on Patients Changes to the Medicare Physician Fee Schedule and Quality Payment Program will shift clinicians’ time from completing unnecessary paperwork to providing innovative, high-quality patient care. Today, the Centers for Medicare & Medicaid Services (CMS) finalized bold proposals that address provider burnout and provide clinicians immediate relief from excessive paperwork tied to outdated billing practices. The final 2019 Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) rule released today also modernizes Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services, no matter where they live. It makes changes to ease health information exchange through improved interoperability and updates QPP measures to focus on those that are most meaningful to positive outcomes. Today’s rule also updates some policies under Medicare’s accountable care organization (ACO) program that streamline quality measures to reduce burden and encourage better health outcomes, although broader reforms to Medicare’s ACO program were proposed in a separate rule. This rule is projected to save clinicians $87 million in reduced administrative costs in 2019 and $843 million over the next decade. “The historic reforms CMS finalized today move us closer to a healthcare system that delivers better care for Americans at lower cost,” said Health and Human Services (HHS) Secretary Alex Azar. “Among other advances, improving how CMS pays for drugs and for physician visits will help deliver on two HHS priorities: bringing down the cost of prescription drugs and creating a value-based healthcare system that empowers patients and providers.” “Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” said [...]

Cigna revenue boosted by commercial growth, now eyes Medicare Advantage

HealthcareDive- AUTHOR -Les Masterson- PUBLISHED- Nov. 1, 2018 Dive Brief: Cigna announced Thursday its revenue increased by 9% to $11.5 billion in the third quarter and credited growth in its global healthcare and supplemental benefits segments. The Bloomfield, Connecticut-based payer's adjusted income from operations increased to $945 million from $716 million a year ago. The payer finished the quarter with nearly 16.3 million medical customers, mostly commercial members. Unlike other payers that have focused more on government health plans, Cigna has only 485,000 members in government plans but is looking at Medicare Advantage as a future growth opportunity. Dive Insight: Cigna continues to grow organically in commercial plans, differing from other payers that are expanding government plans like as Medicare Advantage and Medicaid in the quarter. One reason for Cigna's focus on commercial plans is that CMS barred the payer from the MA market for more than a year. Cigna returned to the the market last year, but missed out on some of the growth other payers have enjoyed in MA. Despite Cigna being behind other payers in MA, the company's CEO David Cordani said the payer still views the plans as an "attractive growth opportunity." Cordani added that Cigna is adding a new market in MA next year and expects a larger expansion in the area in 2020. Cigna said its third quarter revenue increase came from commercial customer growth, expanded specialty relationships and premium increases. Premiums increased from $8.1 million in Q3 2017 to almost $9 million in Q3 2018. For the year, Cigna has picked up about $3 million more in premium revenue compared to 2017. The payer finished the quarter with $27 million in premium revenue for 2018. Cigna has seen membership growth over [...]

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

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

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

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 [...]

How the New U.S. Tax Plan Will Affect Health Care

Harvard Business Review: David Blumenthal- December 19, 2017 The new Republican tax bill, which the House passed this afternoon and the Senate is expected to approve tonight, is complex, but what it will mean for health in the United States is simple: less. It will mean less health insurance for individuals; less coverage for elderly and poor Americans; less revenue for doctors, hospitals, and myriad health care businesses; and, quite possibly, a less-healthy, less-productive workforce. The tax bill will be the most important health care legislation enacted since the Affordable Care Act (ACA) in 2010. The law’s two major health-related aspects are the elimination of the penalties paid by people who fail to have health insurance as required by the so-called individual mandate, and the bill’s overall impact on the federal deficit — which will increase by an estimated $1.45 trillion after allowing for predicted economic growth. According to the Congressional Budget Office (CBO), the repeal of the individual mandate penalties could result in as many as 13 million fewer Americans having health insurance. About 5 million are projected to be people who previously bought health insurance as individuals either within or outside the ACA’s marketplaces. Some will choose not to buy insurance because the penalty has disappeared. Others, especially higher-income individuals who don’t qualify for subsidies under the ACA, will drop insurance because of increases in average premiums predicted by the CBO. These premium increases will occur because, with the repeal of the mandate, many young, healthy people will exit markets, leaving a sicker, more costly insurance pool behind. Older individuals will be most affected. For example, a 60-year-old not receiving subsidies could face premium increases of $1,781, $1,469, $1,371, and $1,504, respectively, in Alaska, [...]

If Republicans Revive Health Care Again, This Is What It Could Mean For Your State

NPR- September 22, 20173:19 PM ET -Danielle Kurtzleben John McCain on Friday imperiled Republicans' latest Affordable Care Act repeal and replace effort when he said he "cannot in good conscience" support the so-called Graham-Cassidy bill. But McCain did also say he could at some point support the substance of his fellow Republicans' proposal. "I would consider supporting legislation similar to that offered by my friends Sens. [Lindsey] Graham and [Bill] Cassidy were it the product of extensive hearings, debate and amendment," McCain said. "But that has not been the case." That's notable because for the first time since Trump became president, there actually seemed to be some real ideological unity around a repeal-and-replace effort from Republicans. Graham-Cassidy Health Bill Would Shift Funds From States That Expanded Medicaid If it is revived — and this effort isn't quite dead yet, because other GOP holdouts haven't stated their unequivocal opposition publicly — the Graham-Cassidy bill very well may be the foundation of how the health care system is reshaped. What would it mean for where you live? We take a look A big selling point of Graham-Cassidy, according to its proponents, is flexibility for states. In place of the federal dollars that fund Obamacare's subsidies and Medicaid expansion, Graham-Cassidy, which under the latest GOP proposal would be law in 2020, would give states block grants. Those are big chunks of money given directly to states, which would have broad discretion in how to spend them. But what's important is that those block grants would be less money than the total money that states are getting for Obamacare right now. Graham-Cassidy would eliminate the premiums that help people pay for their health insurance and the payments helping insurance companies [...]

By |September 23rd, 2017|Blog, Doctor, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Optometrist, Physician Credentialing|Comments Off on If Republicans Revive Health Care Again, This Is What It Could Mean For Your State