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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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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 [...]

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 [...]

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 [...]

The Future of Healthcare Could Be a Privacy Nightmare

TONIC - Susan Rinkunas -Feb 8 2018, 10:54am The Amazon healthcare effort and CVS-Aetna merger raise lots of questions. Last Tuesday, Amazon, JP Morgan, and Berkshire Hathaway announced that they were coming together to do…something related to healthcare for their 1.2 million employees and could possibly expand to the public. We don’t know whether they’ll provide health insurance, offer health clinics at company buildings and/or Whole Foods stores, or just use their size to negotiate better prices with existing insurance companies. Despite the fact that we have next to zero information about what AmazonCare would actually be, the news still sent healthcare stocks falling and led to optimistic predictions and double-takes from doubters. And it has been freaking me out for the past week. Why? Millions of Americans are hooked on Amazon and its two-day shipping. We use it to order toiletries and home supplies, watch movies, and even get our groceries delivered. The site recommends products to you based on your order history. If the parent company is somehow involved in healthcare, it’s not that hard to imagine a world in which Amazon would use people’s health data to suggest products—or even actively try to stop people from buying “unhealthy” things.Is that imagined scenario something that could actually happen or more Black Mirror territory? I talked to a few privacy and health law experts about Amazon—as well as CVS, since CVS pharmacy and health insurer Aetna announced plans to merge in December. While that deal is still pending, it’s also a privacy minefield of healthcare-meets-retail. Initially, they made me freak out even more, but they also reminded me that there are still a lot of unknowns. I asked Frederik Zuiderveen Borgesius, a privacy researcher [...]

Tax on medical devices to resume after 2-year suspension

CNBC via AP- JANUARY 1ST, 2018 While much of corporate America will enjoy a tax cut in the new year, one industry is getting a tax increase it has fought hard but so far unsuccessfully to avoid. A 2.3-percent excise tax on medical device manufacturers is set for reinstatement Monday after a two-year hiatus. It was originally imposed in 2013 as one of several taxes and fees in the Affordable Care Act that pay for expanded health insurance under the law The tax was strongly opposed by the $150 billion a year industry that produces everything from catheters to heart stents to artificial joints. In Congress, it was unpopular not only with Republicans but many Democrats from states like Massachusetts and Minnesota with large numbers of medical device companies. Congress voted to suspend the tax for 2016 and 2017 with the widespread expectation it would be permanently abolished before 2018. But various GOP efforts to repeal the Affordable Care Act and the taxes associated with it failed, and the sweeping federal tax overhaul recently signed by President Donald Trump didn't eliminate the medical device tax either. Industry groups Including the Advanced Medical Technology Association (AdvaMed) and the Medical Imaging & Technology Alliance warn the tax will take a $20 billion bite out of the industry over the next decade. "What we have seen from past experience is that it comes out of funding for product development, research and the jobs associated with those things," said J.C. Scott, AdvaMed's head of government affairs. "We fear we will see employment freezes or reductions and a slowdown in the pipeline for medical innovation." The slashing of the overall corporate tax from 35 percent to 21 percent may soften [...]

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, [...]