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.

­

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

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 [...]

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 [...]

Trump plan: Less health insurance for lower premiums

By RICARDO ALONSO-ZALDIVAR, ASSOCIATED PRESS WASHINGTON — Feb 20, 2018, 4:49 PM ET The Trump administration Tuesday spelled out a plan to lower the cost of health insurance: give consumers the option of buying less coverage in exchange for reduced premiums. The proposed regulations would expand an alternative to the comprehensive medical plans required under former President Barack Obama's health law. Individuals could buy so-called "short-term" policies for up to 12 months. But the coverage would omit key consumer protections and offer fewer benefits, making it unattractive for older people or those with health problems. The plans would come with a disclaimer that they don't meet the Affordable Care Act's safeguards, such as guaranteed coverage, ten broad classes of benefits, and limits on how much older adults have to pay. Insurers could also charge more if a consumer's medical history discloses health problems. Nonetheless, administration officials said they believe the short-term option will be welcomed by people who need an individual health insurance policy but don't qualify for the ACA's income-based subsidies. Those in this largely middle-class crowd make too much for subsidies and have absorbed years of price hikes. Some say they now face monthly, mortgage-size payments of well over $1,000 for health insurance. Then they usually have to pay a deductible of several thousand dollars. Research indicates the uninsured rate among these customers is growing. "If you are not subsidized, the options can be really unaffordable for folks," Health and Human Services Secretary Alex Azar told reporters. The administration estimates monthly premiums for a short-term plan could be about than one-third of what a comprehensive policy costs. Democrats swiftly branded it a return to "junk insurance," and the main insurance industry lobbying group [...]