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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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CVS-AETNA MERGER GETS NY APPROVAL, TO BE FINALIZED THIS WEEK

Health Leaders by BY JOHN COMMINS | NOVEMBER 26, 2018 The approval from New York comes with a boatload of conditions, including enhanced consumer and health insurance rate protections, privacy controls, cybersecurity compliance, and a $40 million commitment to support health insurance enrollment. KEY TAKEAWAYS CVS files notice with SEC stating that the merger will be finalized "on or about Nov. 28." Approval comes two weeks after California gave stipulation-laden approval. Feds approved the deal last month. The $69 billion deal has the potential to fundamentally change healthcare delivery. The megamerger of CVS Health Corp. and Aetna Inc. got the go-ahead Monday from New York state officials, clearing its last hurdle in a $69 billion deal that is expected to be finalized on Wednesday.The approval of New York's Department of Financial Services comes with a boatload of conditions, including enhanced consumer and health insurance rate protections, privacy controls, cybersecurity compliance, and a $40 million commitment to support health insurance education and enrollment and other consumer health protections, DFS said in a media release. "DFS listened to the concerns of the public and has obtained significant commitments from CVS and Aetna to address those concerns, ensuring that the companies hold to their promises of reduced costs and improved health care for New Yorkers, not pass on the costs of this acquisition to New Yorkers, enhance data privacy, and not act in an anti-competitive manner going forward," Financial Services Superintendent Maria T. Vullo said. "DFS will use its full regulatory authority to ensure that the companies adhere to these robust commitments and that both CVS and Aetna are held accountable for promises made to New Yorkers," she said. The approval comes two weeks after the deal cleared another [...]

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

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

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 [...]

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 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. [...]