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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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House GOP plan would cut Medicare, Medicaid to balance budget

Washington Post -  Erica Werner -June 19 at 4:48 PM House Republicans released a proposal Tuesday that would balance the budget in nine years — but only by making large cuts to entitlement programs, including Medicare, that President Trump vowed not to touch. The House Budget Committee is aiming to pass the blueprint this week, but that may be as far as it goes this midterm election year. It is not clear that GOP leaders will put the document on the House floor for a vote, and even if it were to pass the House, the budget would have little impact on actual spending levels. Nonetheless the budget serves as an expression of Republicans’ priorities at a time of rapidly rising deficits and debt. Although the nation’s growing indebtedness has been exacerbated by the GOP’s own policy decisions — including the new tax law, which most analyses say will add at least $1 trillion to the debt — Republicans on the Budget Committee said they felt a responsibility to put the nation on a sounder fiscal trajectory. “The time is now for our Congress to step up and confront the biggest challenge to our society,” said House Budget Chairman Steve Womack (R-Ark.). “There is not a bigger enemy on the domestic side than the debt and deficits.” The Republican budget confronts this enemy by taking a whack at entitlement spending. Lawmakers of both parties agree that spending that is not subject to Congress’s annual appropriations process is becoming unsustainable. But Trump has largely taken it off the table by refusing to touch Medicare or Social Security, and Democrats have little interest in addressing it except as part of a larger deal including tax increases — [...]

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 Change Could Lead To Payments Opportunities

PYMNTS - June 7, 2018 One of the latest changes to federal rules regarding non-medical home care services could provide more business opportunity to firms that serve that market and handle such backend tasks as billing and payroll. In April, the U.S. Centers for Medicare and Medicaid Services (CMS) said that Medicare Advantage would, for the first time, cover those services, through which caregivers help senior citizens in their homes. The decision allows that care to be treated as a supplemental benefit under Medicare Advantage programs. “CMS is expanding the definition of ‘primarily health related’,” the federal agency said. “Under the new definition, the agency will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions and/or reduce avoidable emergency room utilization.” According to the CMS, 35 percent of Medicare beneficiaries take part in Medicare Advantage, with experts predicting significant increases in the years to come. “Insurers and payors have been positioning themselves to better align with post-acute care services for years. As the focus also shifts toward the high-cost, high-needs, dual-eligible patient populations of people who qualify for both Medicare and Medicaid, that has provided additional incentive to cover personal care services as well,” reported Home Health Care News. This is a significant deal for seniors, because they usually pay out of pocket for non-medical home care services, according to experts. And it could turn into a lucrative opportunity for companies active in this market, too. One such company, called Honor, partners with local home care agencies and other providers to manage such tasks as caregiver payroll, recruiting, scheduling, insurance and legal issues. In May, the company accounted a $50 million Series C funding round led by [...]

Trump’s new insurance rules are panned by nearly every healthcare group that submitted formal comments

Los Angeles Times - By NOAM N. LEVEY -MAY 30, 2018 | 3:00 AM | WASHINGTON More than 95% of healthcare groups that have commented on President Trump’s effort to weaken Obama-era health insurance rules criticized or outright opposed the proposals, according to a Times review of thousands of official comment letters filed with federal agencies. The extraordinary one-sided outpouring came from more than 300 patient and consumer advocates, physician and nurse organizations and trade groups representing hospitals, clinics and health insurers across the country, the review found. Kris Haltmeyer, vice president of health policy and analysis at the Blue Cross Blue Shield Assn., said he couldn’t recall a similar show of opposition in his more than 22 years at the trade group, which represents Blue Cross and Blue Shield health plans and is among the organizations that have expressed serious reservations about the administration’s proposed regulations. “This seems to be a pretty overwhelming statement of concern,” Haltmeyer said. State insurance regulators from both political parties have also warned that the administration’s proposals could destabilize insurance markets, raise premiums for sick Americans and open the door to insurance fraud. And dozens of industry leaders and other experts have called on the administration to rethink moves to scale back consumer protections enacted through the Affordable Care Act, often called Obamacare. “Basically anybody who knows anything about healthcare is opposed to these proposals,” said Sandy Praeger, a former Republican state insurance regulator in Kansas and onetime president of the National Assn. of Insurance Commissioners. “It’s amazing.” Obamacare 101: A primer on key issues in the debate over repealing and replacing the Affordable Care Act. » After the failure to repeal the healthcare law last year, the Trump administration is [...]

By |May 30th, 2018|Blog, Commercial Insurance, Consulting, Credentialing, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing, Staff Training|Comments Off on Trump’s new insurance rules are panned by nearly every healthcare group that submitted formal comments

Medicare Advantage Data Could Strengthen Outcomes, Spending Research

HCA News- Jared Kaltwasser -MAY 18, 2018 CMS plans to begin releasing Medicare Advantage (MA) data to health researchers, in a move that could substantially improve the quality and robustness of public health analysis. “We recognize that the MA data is not perfect, but we have determined that the quality of the available MA data is adequate enough to support research,” CMS Administrator Seema Verma, MPH, said during last month’s announcement. “And although this is our first release, going forward, we plan to make this data available annually.” Gerard Anderson, PhD, a professor at the Bloomberg School of Public Health at Johns Hopkins University, said the data will be an important piece of the puzzle as researchers track health usage, spending, and outcomes. “Many us have been using Medicare fee-for service-data for 30-plus years,” he told Healthcare Analytics News™. “We did not have access to the same data on MA plans, and this made it difficult to determine if the care was better in MA plans than it was in fee for service. It also allows us to compare the mix of services that each program receives.” CMS makes privacy-protected claims data available to researchers through its Virtual Research Data Center (VRDC), which Verma said has information on CMS’ 130 million current enrollees, as well as data from patients who previously were covered by CMS programs. “If you’ve seen a study that references Medicare data, it probably came from an analysis of data in the VRDC,” Verma said. The Medicare Advantage release wasn’t Verma’s only announcement. She said CMS will make additional databases available in the coming years. “Next year, we expect to make Medicaid and Children’s Health Insurance Program data available,” she said. “This means [...]

Trump Promises Lower Drug Prices, but Drops Populist Solutions

NY Times-  By Robert Pear May 11, 2018 WASHINGTON — President Trump vowed on Friday to “bring soaring drug prices back down to earth” by promoting competition among pharmaceutical companies, and he suggested that the government could require drugmakers to disclose prices in their ubiquitous television advertising. But he dropped the popular and populist proposals of his presidential campaign, opting not to have the federal government directly negotiate lower drug prices for Medicare. And he chose not to allow American consumers to import low-cost medicines from abroad. He would instead give private entities more tools to negotiate better deals on behalf of consumers, insurers and employers. Speaking in the sun-splashed Rose Garden of the White House, Mr. Trump said that a “tangled web of special interests” had conspired to keep drug prices high at the expense of American consumers. “Everyone involved in the broken system — the drugmakers, insurance companies, distributors, pharmacy benefit managers and many others — contribute to the problem,” Mr. Trump said. “Government has also been part of the problem because previous leaders turned a blind eye to this incredible abuse. But under this administration we are putting American patients first.” His proposals hardly put a scare into the system he criticized. Ronny Gal, a securities analyst at Sanford C. Bernstein & Company, said the president’s speech was “very, very positive to pharma,” and he added, “We have not seen anything about that speech which should concern investors” in the pharmaceutical industry. Shares of several major drug and biotech companies rose immediately after the speech, as did the stocks of pharmacy benefit managers, the “middlemen” who Mr. Trump said had gotten “very, very rich.” The Nasdaq Biotechnology Index rose 2.7 percent on Friday. [...]

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 [...]