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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

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 [...]

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 [...]

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 [...]

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 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. [...]