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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 [...]

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 [...]

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 [...]

What merger mania means for health care

CNN Money- by Paul R. La Monica- March 8, 2018: 12:32 PM ET Get ready for another wave of massive health care deals -- and maybe this time the government will approve them. Health insurer giant Cigna's proposed purchase of pharmacy benefits manager Express Scripts for $67 billion comes just three months after Cigna rival Aetna agreed to be bought by drugstore chain CVS (CVS) for $69 billion. The insurance companies have been forced to find alternative ways to adapt and grow in a rapidly changing health care industry after the Justice Department blocked two massive deals involving four of the five biggest health insurers on antitrust grounds a year ago. Cigna (CI) and Anthem (ANTM) called off their proposed combination in February 2017 -- and rivals Aetna (AET) and Humana (HUM) announced they were ending plans to merge on the same day. UnitedHealth (UNH) is the other major health care insurer. But the Cigna-Express Scripts and CVS-Aetna deals, in theory, have a better chance of getting approved by regulators since they are so-called vertical, as opposed to horizontal, mergers. In plain English, that means the mergers aren't ones where two similar companies are looking to combine and take a competitor out of the market. Instead, they're trying to add a new line of business. Still, the deal between Cigna and Express Scripts (ESRX) is yet another clear sign that the health care industry in America could soon be dominated by just a small handful of giant conglomerates. For example, the pharmacy benefits management industry, which negotiates with the big drug makers to try and get better prices on prescription medications for consumers, is already dominated by Express Scripts, CVS and UnitedHealth. If CVS gets approval to [...]

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 [...]

Trump urges insurers to work together to ‘save Americans from Obamacare’

Will Obamacare survive? Washington Post - By Carolyn Y. Johnson and Juliet Eilperin February 27 at 12:19 PM  President Trump met with major health insurers Monday morning, in the midst of political divisions over how to dismantle and replace President Obama's signature health-care law, the Affordable Care Act, and intensifying public pressure to preserve the policy. The meeting included leaders from Blue Cross Blue Shield, Cigna, Humana, UnitedHealth Group, Aetna, Anthem, Kaiser Permanente and the industry lobbying group, America's Health Insurance Plans. "We must work together to save Americans from Obamacare," Trump said in public remarks before the closed-door meeting. He criticized the Affordable Care Act, commonly known as Obamacare, for creating minimal health coverage requirements that restricted the types of plans insurers could sell. "Obamacare forced providers to limit the plan options they offered to patients and caused them to drive prices way up," Trump said. "Now a third of U.S. counties are down to one insurer, and the insurers are fleeing. You people know that better than anybody." Over the past month, more insurers have warned that they could pull out of the Affordable Care Act’s health-care exchanges where individuals can buy government-subsidized insurance. Aetna chief executive Mark Bertolini has described the exchanges as being in a "death spiral." Humana — which insures about 150,000 people on the exchanges this year — announced in mid-February it would exit the exchanges in 2018. In an earnings call, Molina Healthcare disclosed that its exchange business lost $110 million in 2016 and said it would evaluate its participation for next year on a state-by-state basis. A Molina spokeswoman said the company, which insures 1 million members through the exchanges, was not invited to the meeting. Trump gave [...]

The Trump administration just proposed big changes to Obamacare

Will Obamacare survive? Business Insider- Feb. 15, 2017, 9:54 AM- Bob Bryan The Centers for Medicare and Medicaid Services on Wednesday morning announced new proposed rules for the Affordable Care Act's individual insurance exchanges. The proposals from CMS include several changes to enrollment periods and timelines for insurers in an attempt at "stabilizing the individual and small group health insurance markets," according to a press release. The proposed changes would be the first administrative tweaks to the law, also known as Obamacare, under President Donald Trump's administration. They contain a combination of long-considered ideas and serious departures from the previous administration. Perhaps the two most striking proposed changes are cutting in half the exchanges' 2018 open enrollment period and lowering minimum standards for care to qualify for the exchanges. The CMS proposes an open enrollment period — during which people without health insurance through their employer or Medicaid/Medicare can sign up for coverage — from November 1 to December 15, 2017. Open enrollment periods have been three months, from November 1 to January 31. Additionally, the rules would lower the "de minimis range used for determining the level of coverage," according to the release. Essentially, the ACA established minimum standards for coverage (here's a full breakdown from CMS) in order to be certified on the bronze, silver, and gold plan levels. The new rule would allow insurers to cover slightly fewer areas of health and still be at a certain metal level. The CMS projects the rules would result in increased out-of-pocket costs for Americans in the short term but that lower premiums would offset this in the long run. "The proposed change in [actuarial value] could reduce the value of coverage for [...]

As Obamacare Repeal Stalls, Republicans Face New Challenges

Will Obamacare survive? NBC News - Benjy Sarlin -FEB 8 2017, 9:55 AM ET President Donald Trump caused a stir when he suggested Sunday that the Republican Party's quest to repeal and replace the Affordable Care Act might continue through 2018. But some Republicans think he might be on to something. "I know there was some hyperventilating about the president's comments that this could spill into next year, but that didn't bother me," Rep. Charlie Dent, R-Pennsylvania, said as he left a caucus meeting Tuesday. "I thought it was fairly realistic." "I do think slowing down would be wise," Rep. Tom MacArthur, R-New Jersey, told NBC News when asked about Trump's comments. Trump's remarks come as efforts to repeal and replace the Affordable Care Act, which began with a bang after the election, are lagging amid internal debates over the substance of a Republican health care plan and the process used to pass it. The current plan is a delicate multi-step path that requires Republicans to use the budget reconciliation process to partly repeal Obamacare by a majority vote and install some elements of a Republican plan, then negotiate with Democrats later on a full replacement, which would require 60 Senate votes. Republicans can't manage many defections — they have only 52 votes in the Senate — and consensus has so far been elusive. On one hand, conservatives are eager to fulfill the Republican Party's longtime promise to repeal the law and replace it with a less expensive plan with fewer taxes and more free-market principles. On the other hand, more moderate Republicans are concerned that removing too much of the law too fast could wreck the insurance market and that some conservative [...]

Senate Takes First Step To Repeal Obamacare — So What’s Next?

Will Obamacare survive? NPR -January 12, 20175:04 AM ET Heard on Morning Edition - Danielle Kurtzleben / Alisa Chang -With reporting from Susan Davis. At about 1:30 a.m. on Thursday, Republicans moved one step closer to repealing a law they have railed against since the moment it was passed nearly seven years ago. By a final vote of 51-48, the Senate approved a budget resolution that sets the stage for broad swaths of the Affordable Care Act to be repealed through a process known as budget reconciliation. The resolution now goes to the House, where leaders are hoping to approve it by the end of the week. The powerful tool sets up a fast track for repealing large parts of Barack Obama's major domestic achievement; the best guess is that the Senate is still several weeks away from largely repealing Obamacare. But as the process continues, large questions still loom over how — and when – Republicans will replace the health care law. An expedited repeal, starting with a vote-a-rama The vote took place during a session known as a "vote-a-rama." These all-night vote-fests happen surrounding budget resolutions, which allow senators to propose unlimited amendments, as the New York Times' Thomas Kaplan explained this week. The passage of the resolution kicks off the budget reconciliation process. That process is special because a reconciliation measure cannot be filibustered, meaning it allows the Senate to pass a bill with a simple majority (as opposed to needing 60 votes to overcome a filibuster). That's good for Republicans, who hold 52 of the Senate's 100 seats. Once the House approves the measure, which could happen as soon as Friday, committees from both chambers will meet to create [...]