Tag Archives: insurer
CMS Speaks: Weigh Your 2-Payer Consult Coding Options
Posted on 18. Mar, 2010 by Editor.
In MSP cases, non-consult code for both payers may be best.
If you have payers who didn’t play follow-the-leader with Medicare in cutting out consult codes, you have a dilemma on your hands. You have to decide what to do when your physician performs a consult, the primary insurer pays you for the service, and Medicare is the secondary payer.
Map Out a Strategy From MLN Article
CMS announced the “Medicare Secondary Payer (MSP) will not pay for consults,” says Samantha Daily, billing specialist with a practice in Portland, Ore.
Recently published MLN Matters article MM6740 indicates the following: “In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation …]. If the primary payer for the service continues to recognize consultation codes,” you should bill in one of the following two ways:
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Payer Update: UHC Sticks With Consult Codes
Posted on 12. Jan, 2010 by Editor.
Check with Medicaid plans, insurer warns.
You can breathe a sigh of relief — one major payer will stick with 99241-99255.
UnitedHealthcare (UHC) commercial plans will make no change in payment for consultation codes (99241-99255) at this time, according to a UHC e-mail alert. “Physicians may continue to submit claims for these services, and will be reimbursed according to United-Healthcare payment policies”.
Beware: One Medicaid plan will eliminate consult pay and force you to follow Medicare’s rule of using office and hospital codes in lieu of 99241-99255. “For AmeriChoice Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS rules and implement the change effective January 1, 2010,” the email notice states. “For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed otherwise by a state to pursue other strategies.”
Watch your mail for a UHC payer news notice and an article in the January Network Bulletin.
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FREE WEBINAR THIS MONTH: 2010 Consult Coding Update, with Jennifer Godreau.
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Big Insurers Underspend On Medical Care, Senate Probe Finds
Posted on 03. Nov, 2009 by Editor.
Which big health insurance company did lawmakers single out? Is it the one that gives you the most denials trouble?
A US Senate probe confirms what many coders and billers have been suspecting all along — that six major medical insurers aren’t spending as much as they should providing actual health care.
Insurance industry officials say that all health insurers spend an average of 87 cents of every dollar on medical care, reports The Wall Street Journal. For the trade-group-curious, America’s Health Insurance Plans (AHIP) came up with the ‘87 cents’ figure.
And I bet you can tell me the names of the insurers that ‘underspend’ without reading the rest of the article. But just for grins — they’re Aetna Inc., Cigna Corp., Coventry Health Care Inc., Humana Inc., Unitedhealth Group Inc. and Wellpoint Inc., reports the Journal. These big fish spend an average of 74 cents on every dollar individuals pay in premiums on medical care (if they’re on individual plans). That figure goes up a bit for small group (80 cents). However, even the large group insurance average (84 cents) for these six insurers doesn’t hit AHIP’s estimate of how much premium money goes to actual medical care.
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A Coder’s Guide to Health Care Reform
Posted on 24. Aug, 2009 by Editor.
Quick way to show your practice you’re prepared for the unknowns ahead.
If anyone should be able to understand the complicated health care reform debate raging in Washington, it should be us coders and billers, right? After all, we’re closest to what’s at the center of the debate: dollars and cents.
So, if you’re like me, you’ve been wading through the long newspaper articles about health reform because there are lots of people at work who expect you to understand it. And if you’re like me, you quickly get overwhelmed and wish you were reading Cathy instead.
Help is here — a quick n’ easy health reform “fake book” from Back of the Napkin author Dan Roam and Tony Jones, MD. Simple slides and drawings outline health reform possibilities, and how each one will affect providers, patients and insurers.
Tip: We coders and billers can quickly zip through the first few slides that explain “health care is a business.” Yeah. We know.
Things get more interesting when Roam and Jones sketch out which proposals in Congress have a chance of passing, and which are just hype. Juicy tidbit: They point out that “private insurers had a remarkable profitable 2008. (Yes, in the recession.)”
So become a health care reform guru, wow your boss, and get promoted. Check out the ‘Back of the Napkin Guide to Health Care Reform’ here. (And thanks to attorney Bob Coffield’s blog for the lead.)
Whatever happens, health care will always need certified coders. Train for your CPC® exam here.
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Pssssssst. Payer Report Cards Are Out
Posted on 05. Aug, 2009 by Editor.
If you know your payers’ strengths and weaknesses, you’re better equipped to fight denials and negotiate contracts that are in your best interest.
So check out the American Medical Association’s second annual National Health Insurer Report Card. The AMA has gathered data and rated large payers on criteria like payment timeliness, accuracy, claim edit sources and denials, according to an American Medical News article that summarizes trends in the report card.
Drawback: The AMA’s payer report card looks only at big, national insurers (Aetna, Anthem, Blue Cross and Blue Shield, Cigna, Coventry, Health Net, Humana, UnitedHealthcare and Medicare). To get the dirt on smaller or regional payers, check out this resource from Athenahealth.
To see the AMA’s payer report card, go here.
Are your payers ‘remedial’ at best? USE THE APPEALS PROCESS LIKE A PRO, with APPEALS QUEEN Barbara Cobuzzi.
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Tool: How Do Your Payers Measure Up?
Posted on 12. Jun, 2009 by Editor.
Coders & Billers: Can you feel your life getting a little easier? Overall, payers are reimbursing providers faster (up 5.3% from last year) and denying 9% fewer claims.
That’s according to Athenahealth, an online medical billing service that has ranked 172 health insurers nationwide for how well they pay up in the physician and hospital arenas. Among the 7 health insurance giants, Humana ranked first, and Coventry Health Care came in last. For more winners and losers, see this summary from Athenahealth.
Cool Tool: Also on the site, a revealing window into how well YOUR PAYERS stack up. Simply select your region, and see how the ‘usual suspects’ rank overall, as well as in particular areas, such as timeliness and ‘transparency’ of denials.
Still don’t feel like you can relax and break out the bubblebath just yet? That’s OK. Audioeducator has an on-demand class coming up that teaches you how to USE THE APPEALS PROCESS LIKE A PRO, with APPEALS QUEEN Barbara Cobuzzi.
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CIGNA Opens Black Box: Get Paid With Modifiers 25 & 59
Posted on 07. May, 2009 by Editor.
You now have clear-cut policies to apply, including 1 on 96110 pay.
Say goodbye to secret black box bundles and hello to transparent CCI edits for one more insurer.
Adhere to CCI Edits, CMS Modifier Guidelines
Effective April 20, “CIGNA will apply CMS National Correct Coding Initiative (NCCI) Incidental and Mutually Exclusive edits,” according to the payer’s March 2009 Network News. The change puts the insurer’s policy on a level playing field.
For years, CIGNA did their own thing, points out Patti DiSpazio, CPC, business manager at Island Coast Pediatrics in Fort Myers, Fla. “Following UHC’s change, they’re using CCI edits as a barometer.”
In addition, the payer will adopt many CMS modifier guidelines. “Modifier policies being updated are Modifiers 21, 22, 25, 59, 80, 81, 82 and AS,” CIGNA says.
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Insurers Offer to Charge Sick People Less …
Posted on 01. Apr, 2009 by Editor.
… and healthy people more.
In an unexpected move last week, Karen M. Ignagni, president America’s Health Insurance Plans, told lawmakers that the health insurance industry is willing to change its policy of charging sick people higher premiums, reports The New York Times. The trade group says the industry will make up for the shortfall by charging healthy people higher premiums than they pay now.
We’re skeptical, some observers tell Coding News. The AHIP’s recent concession may well be a way to dodge any discussion about universal health care in Congress. And how do insurers intend to treat providers, given that most of the industry’s current rhetoric is about patients? More …
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10 Carrier Contract Negotiation Tips
Posted on 06. Mar, 2009 by Editor.
Carrier contract negotiation is often a long, difficult process. If you don’t ask the right questions, you could end up in a binding contract that doesn’t work well for your practice. Don’t sign a new carrier contract without reviewing the following 10 items first:
• Speak up. Don’t let carriers make you feel intimidated. Negotiate for what will help, not hurt, your practice.
Going mano-a-mano with Medicare? You’ve got to know these rules.
• Avoid boilerplate text. Standard contracts don’t work for all practices. Make sure you read each word, and don’t skip over “standard” wording.
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Show Us the Money for Primary Care
Posted on 05. Feb, 2009 by Editor.
Almost everyone agrees that federal and private insurers should reimburse primary care doctors more for their E/M skills and preventive care work.
But where should that extra reimbursement come from? Let’s lower the reimbursement specialists receive so we can pay primary care docs more, said readers in a recent Wall Street Journal Health Blog survey.
The American College of Physicians begs to differ. Pay primary care doctors more, the group argues, AND continue to pay specialists at the same rate. If the health care system doesn’t take that approach, primary care reimbursement will get lost as all the specialties wrangle over cash … More …
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