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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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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 [...]

Google sister-company Verily is plotting a move into a fast-growing corner of the health insurance industry

CNBC -Christina Farr | @chrissyfarr -Updated 11:27 AM ET Tue, 27 Feb 2018 Verily's new hires and partnerships point to a move into health insurance. The company is looking to take on risk for patient populations and sharing in the upside if it can bring down health-care costs, sources tell CNBC. The opportunity is currently in the tens of billions, with the potential to grow into a trillion dollar market. Alphabet's health-care unit Verily is moving ahead with plans in the insurance sector with new hires and partnerships. Three people familiar with the company's plans say Verily, the group formerly known as Google Life Sciences, has been in talks with insurers about jointly bidding for contracts that would involve taking on risk for hundreds of thousands of patients. In 2016, it mulled jointly putting in a proposal with Alphabet-backed insurer Oscar Health to manage care for thousands of low-income Rhode Island residents on Medicaid, one of the sources said, but ultimately decided against it. Now, it is moving ahead with plans to enter into this market, which health insiders often refer to as "population health" or "care management." The population health market is large and growing, but crowded. To enter this space, a vendor like Verily would put forward a proposal to a payor — like the government, an employer or a private insurance company — detailing how it can bring down costs. If a company like Verily can deliver on that, the payor would share some portion of the amount saved. If costs don't come down, it might make no money from that contract. (This is a simplification, and the details vary by contract.) A classic intervention might involve analyzing health data to figure [...]

By |March 2nd, 2018|Blog, Consulting, doctor, doctor Credentialing, Healthcare Changes, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing, Verification|Comments Off on Google sister-company Verily is plotting a move into a fast-growing corner of the health insurance industry

One in four U.S. consumers have had their personal medical information stolen

The Accenture study also finds that half of these victims were subject to medical identity theft and on average had to pay $2,500 in out-of-pocket costs per incident. Healthcare IT News - By Bill Siwicki February 20, 201708:23 AM Twenty-six percent of U.S. consumers have had their personal medical information stolen from healthcare information systems, according to results of a new study from Accenture released today at HIMSS17 in Orlando. The findings show that 50 percent of those who experienced a breach were victims of medical identity theft and had to pay approximately $2,500 in out-of-pocket costs per incident, on average. In addition, the survey of 2,000 U.S. consumers found that the breaches were most likely to occur in hospitals (the location cited by 36 percent of respondents who experienced a breach), followed by urgent-care clinics (22 percent), pharmacies (22 percent), physicians’ offices (21 percent) and health insurers (21 percent). 50 percent of consumers who experienced a breach found out about it themselves, through noting an error on their credit card statement or benefits explanation, whereas only 33 percent were alerted to the breach by the organization where it occurred, and only 15 percent were alerted by a government agency, according to the survey. Among those who experienced a breach, 50 percent were victims of medical identity theft, the survey found. Most often, the stolen identity was used to purchase items (cited by 37 percent of data-breached respondents) or used for fraudulent activities, such as billing for care (37 percent) or filling prescriptions (26 percent). Nearly one-third of consumers had their social security number (31 percent), contact information (31 percent) or medical data (31 percent) compromised, according to the survey. Unlike credit card identity theft, where [...]

The Advantages and Disadvantages of Electronic Medical Records

Credentialing, Revalidation Services professionals at The Firm Services Crystal Lombardo- The Next Galaxy  The advancement of technology has changed the way the entire world functions. One big change that has happened has to do with the medical world. Electronic medical records, or EMR’s, are used in just about every single hospital and doctor’s office in the United States. Electronic medical record means that a patient’s paper chart, which is what contains all of their medical history, information on medical conditions, treatments, and other types of information, are all stored electronically. It has been a great asset to the medical community, but has brought some pretty hefty issues right along with it. Advantages of Electronic Medical Records 1. Instant Access is an Advantage EMR give medical professionals quick and simple access to all of the patient information that they may need in order to provide an accurate and speedy diagnosis. Much of the confusion, and bureaucratic characteristics of the medical world are eliminated with the use of electronic medical records. 2. Doctor’s Have Bad Handwriting It is no secret that the majority of doctors have pretty illegible penmanship. This has been a problem that has haunted the medical world for decades. Electronic medical records have solved this problem! Doctors no longer have to scribble notes that may not be able to be read, instead they type them into the electronic medical record database, so there is never anymore confusion about if that is an “r” or a “z”. 3. Record Keeping Has Been Cleaned Up Keeping a physical record for each patient can begin to take up a pretty intense amount of space. Boxes and boxes of records are filed in order to be [...]

100,000 PEOPLE SIGN UP FOR OBAMACARE ON DAY DONALD TRUMP PRESIDENCY ANNOUNCED

Will Obamacare survive?      Newsweek- BY CONOR GAFFEY ON 11/11/16 AT 5:25 AM More than 100,000 Americans signed up for health care plans under President Barack Obama’s “Obamacare” policy Wednesday after Donald Trump clinched victory in the presidential election. U.S. Secretary of Health and Human Services Sylvia Burwell tweeted Thursday that a record number of signups had been recorded on November 9, when it became clear that Trump—who has promised to repeal the healthcare legislation—would become the 45th U.S. president. Wednesday’s figure is the highest since open enrollment—the annual three-month period during which Americans can apply for health insurance plans—began on November 1. Best day yet this Open Enrollment. Nov 9: Over 100K plan selections on http://HealthCare.gov . Consumers shopping & enrolling. #GetCovered Commenting on the large number of signups, White House Press Secretary Josh Earnest said that it was “an indication of the intense demand” for affordable health care plans among Americans, USA Today reported. Congressional Republicans Plan to Target Obamacare The Patient Protection and Affordable Care Act passed in 2010 and was the largest overhaul of the U.S. health care system in half a century. The act has extended health care coverage to a further 20 million people but has forced up insurance premiums for private health care customers. Trump has promised to begin the process of repealing Obamacare “on day one” of his administration. The Republican will be sworn into office on January 20, 2017. The Republican party, including House Speaker Paul Ryan, has expressed its commitment to getting rid of Obamacare. Senate Majority Leader Mitch McConnell told reporters in Washington on Wednesday, following the news that Trump had been elected, that repealing Obamacare was “a pretty high item on our agenda” [...]

Dems use ObamaCare crisis to revive ‘public option’ push

By Barnini Chakraborty Published September 07, 2016 FoxNews.com President Obama and his Democratic allies are seizing on the exodus of private insurers from ObamaCare markets to renew their push for a so-called "public option" -- but Republicans say more "government intervention" is not the answer to the latest Affordable Care Act woes. A public option -- or insurance plan offered by the government -- had been written into early versions of the bill but failed to make the final cut in the law signed by Obama in March 2010. But with many states seeing private insurers exit ObamaCare markets amid concerns over cost and other factors, Democrats see a silver lining to what critics are calling another ObamaCare crisis -- a reason to bring the option back. “Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited,” Obama wrote last month in the Journal of the American Medical Association. The president called on his White House successor and Congress to implement the option. A former Obama health official, Ezekiel Emanuel, also backed up the president in a recent op-ed. And ex-Obama campaign manager David Plouffe added his support in an interview with NBC's "Meet the Press." If elected, Democratic presidential nominee Hillary Clinton says she’ll look for ways to improve ObamaCare, which includes supporting a public option. Her Republican rival Donald Trump and several GOP lawmakers, though, say the public option isn’t an option at all. Sen. John McCain, R-Ariz., who is seeking a 6th term, has been a vocal opponent of ObamaCare from the start and maintains “the whole thing is collapsing like a house [...]

The government just announced some big changes to try to fix Obamacare

Business Insider-Bob Bryan -August 29,2016 The government is offering some ideas to try to fix the Affordable Care Act, the healthcare law known as Obamacare, amid a series of missteps that have befallen President Barack Obama's signature legislative achievement. With Obamacare having being dogged by negative news over the past few weeks — as major insurers have pulled out of some public exchanges and regulators have said the exchanges are "near collapse" — the US Centers for Medicare and Medicaid Services, or CMS, proposed a series of changes on Monday to try to correct some of the exchange issues. CMS, the division of the US Department of Health and Human Services that oversees the exchanges, proposed tweaks that would make it less risky for insurers in the marketplace to take on sick patients. Two of the biggest problems for the exchanges have been a lack of young people, who help offset higher-cost patients, signing up for insurance and generally sicker-than-expected people getting coverage through the exchanges, leading to huge losses for some insurers. A few of the 14 total proposals include: Using some of the fees from the federally funded marketplace for outreach to get more young people to sign up. Strengthening rules for signing up for insurance outside the open-enrollment period to ensure that people are not waiting until they are sick to get coverage. Take prescription-drug use into account when evaluating the risk profile of potential patients. Previously, this had not been taken into account, and insurers argued that it prevented them from getting a full picture of possible patients' health status. Creating more flexibility for insurers in their bronze plan offerings to reduce cost burdens. Kevin Counihan, the insurance marketplace CEO at [...]

Aetna to cut back 70% on Obamacare plans in 2017

Have questions about Obamacare and Aetna ?Call us we can help. Aetna is sharply cutting its participation in Obamacare exchanges for 2017. The health insurer said it will offer individual Affordable Care Act exchange plans in just four states, down from 15 this year, in an effort to reduce its losses. "As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision," Chairman and CEO Marc Bertolini said in a statement. The insurance giant says it will offer ACA exchange plans in Delaware, Iowa, Nebraska and Virginia, slashing its Obamacare footprint by 70 percent next year. It will offer ACA plans in just 242 counties nationally, down from nearly 780 this year. Aetna's announcement comes two weeks after the company booked $200 million in ACA-related pretax losses in its Q2 earnings report and nearly one month after the Department of Justice's antitrust division sued to block the health insurer's acquisition of rival Humana. Humana has also announced it will sharply cut back from the exchanges. Its pullback, in the wake of UnitedHealth's departure from all but a handful of exchanges, means that hundreds of thousands of Obamacare plan members will no longer have access to plans from the nation's three major insurers in 2017. Aetna has been one of the largest Obamacare players since the launch of the exchanges two years ago, offering plans in more than two dozen states. The Obama administration's chief executive of the federal marketplace attributed the insurer's departure to the forces of competition in an evolving insurance market. "Aetna's decision to alter its Marketplace participation does not change the fundamental fact that the Health Insurance [...]

ICD-10 conversion had minimal impact on hospitals’ denial rates, report finds

Written by Kelly Gooch | June 29, 2016 After three delays and much industry opposition, the United States' healthcare industry transitioned Oct. 1, 2015, to ICD-10, increasing the number of diagnostic codes from 13,000 to 68,000. The transition was expected to have far-reaching, disruptive consequences, such as delays in billing and coding, the potential for increased payer denials and accounts receivable and the possibility of decreased cash collections. However, new data shows the conversion minimally impacted cash collections, initial denial rates and days in accounts receivable, according to a report from public accounting, consulting and technology firm Crowe Horwath. This data came from Crowe Revenue Cycle Analytics, a benchmarking solution that compiles and organizes a daily feed of transactional-level data from the patient accounting systems of nearly 600 hospitals. These reports outline findings based on an assessment of key performance indicators related to billing and coding, accounts receivable and denials. The Crowe report details the analysis of data examined through March 31. Here are four findings from the report. 1. On average, there was minimal impact on cash collections, initial denial rates and days in accounts receivable due to the ICD-10 conversion; however, there were delays in inpatient billing and coding, Crowe said. This resulted in a 10.1 percent increase in inpatient discharge and not final billed days from October through December 2015, compared to the same period in 2014. 2. Crowe observed a temporary increase in denial claim adjustment reason code 11, indicating the diagnosis is inconsistent with the procedure, for a small number of hospitals. As a percentage of total gross patient services revenue, this denial reason code spiked from October through December 2015. Brian Sanderson, managing principal of Crowe healthcare services, said [...]

ICD-10 Works, but Concerns Remain Over Audits, Productivity

Let The Firm services assist you. By James Swann Feb. 24 — The switch to ICD-10 five months ago was uneventful, but concerns about provider productivity using the new codes and the threat of increased government audits remain among industry stakeholders. Specifically, providers need to make sure their claims contain enough detail to support the selected ICD-10 code, George B. Breen, an attorney with Epstein Becker & Green, in Washington, said. While Breen said it's too early to expect federal enforcement action involving ICD-10 coding, providers should expect the government to be focusing on appropriate clinical documentation to support claims coding. Providers need to look at ICD-10 through the prism of the increasing government focus on value-based payments, Breen said. “Health-care entities also need to anticipate and be prepared to respond to aggressive payer audits, both private and public,” Breen said. Providers are currently operating under a one-year grace period from the Centers for Medicare & Medicaid Services during which Medicare contractors won't deny claims as long as a valid ICD-10 code from the right coding family is used. The grace period means that a claim won't be denied if it isn't as specific as required under ICD-10. Breen said providers should take advantage of the time to create effective audit protocols that can address ICD-10 issues. “An open question that providers must determine an answer to is whether the grace period also permits that same flexibility in an overpayment analysis,” Breen said. While the grace period will prevent outright claims denials, Breen said, it's uncertain whether the CMS will offer a similar dispensation for any nonspecific ICD-10 claims that result in overpayments. The International Classification of Diseases, 10th Revision (ICD-10), which took [...]