What Insurance Companies Don’t Want You to Know! Friday, Oct 26 2012 

Finally! A long awaited and much anticipated book about ERISA by two well-respected leaders in the health care industry! This book will provide the secrets in getting claims paid, how to fight denials, and halt recoupments using the features within the ERISA regulations.

This is a must buy! Quite frankly, this is important even if you are a layperson covered under your employer’s group health plan! These are the secrets that your insurance company doesn’t want you or your doctor’s office to know!

Book Description

Publication Date: October 15, 2012
New book helps medical practices use the secrets within the ERISA regulations to their benefit to increase practice profitability The Medical Practice Guide to ERISA: Employee Retirement Income Security Act The Federal law ERISA (Employee Retirement Income Security Act) helps the majority of medical practices make carriers pay on claims that are now being denied, delayed and recouped. Only a small percentage of practices understand how ERISA works — yet with this new book, ERISA could possibly become a practice’s best friend! ERISA is complex and most medical practices, “Don’t know what they don’t know when it comes to dealing with ERISA!” Practices are in the dark in understanding how to protect their employer’s rights in collecting the monies owed them. ERISA regulates the practice s health benefits, health benefit payments, EOBs, and most importantly, appeal rights Using this book will allow the reader to not only capture the funds on thousands of dollars that the carriers are now unfairly denying, but will empower the reader to stop the unfair recoupments, illegal timely filing and improper appeal periods that carriers mistakenly quote to physicians and hospital offices. The authors map out the smart but ingeniously simple tactics that practices can use to force insurance carriers to honor their responsibilities on the policies owned by patients — and to convince the carriers to adhere to what the policies actually require them to cover. Providing an overview of the ERISA law, the Self/Verno book provides tips, tools and techniques to leverage ERISA for practice advantage. They take a close look at real-world ERISA situations, violations and outcomes. Armed with this roadmap, physicians and executive staff can better put their resources to work– leveraging ERISA to improve practice profitability. Noteworthy Features Clear Roadmap Written in layman’s terms so practice leaders can immediately begin to implement a strategy of getting claims paid, how to fight denials and halt recoupments. Practical Guidance Includes real world examples and case studies of how medical practices can use the ERISA rules to work for them. Also included is practical information on how to use the ERISA website and answers to the most frequently asked questions about ERISA. Templates to Get You Started Sample letters (describing exact situations and how they can be handled) will get you started and help your practice take control of the process. Selected Table of Contents Healthcare Basics Definitions Laws Employee Benefits Security Administration: Frequently Asked Questions about ERISA Using ERISA Claims Issues Sample Letters – Timely Filing Denial Response, Refund Demand Layperson Response, Unpaid Claims Letter, Incorrectly Paid Claims Letter, Bundling Denial Letter, Down Coding Letter, Payment to Patient Letter Additional Resources – Helpful Websites, Layperson Documents Authorized Representation, Assignment of Benefit Form

You can purchase through Amazon by clicking on this link:

http://www.amazon.com/The-Medical-Practice-Guide-ERISA/dp/0988304007/ref=pd_rhf_cr_p_t_1

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ICD-10-CM implementation date is October 1, 2014 Saturday, Sep 1 2012 

The final rule setting the ICD-10-CM implementation date as October 1, 2014 was released by the Centers for Medicare & Medicaid Services (CMS) on August 24, 2012.

Why am I being Charged for my “FREE” physical? Saturday, Sep 1 2012 

Due to the Patient Protection and Affordable Care Act (PPACA), or commonly called “Obamacare”, Health Plans are starting to cover Preventive Medicine services at 100% with no copays, coinsurance or deductible. Unfortunately, insurance companies are not informing patients that dealing with medical issues during these preventive medicine visits will result in an out-of-pocket charge that could result in a co-payment, or a substantial out-of-pocket expense if they have not met their deductible. Insurance companies require all services to be itemized and coded appropriately. One of the primary reasons is to prevent the health plans from paying for services that are not covered. Providers cannot code problem visits as preventive because this would be insurance fraud and could result in the insurance company denying the claim, dropping the physician from their network, and/or, if a government plan, the physician can face imprisonment and fines.

This has resulted in patients becoming angry with their doctor’s offices. Many practices are trying to figure out how to deal with this issue. At my practice, we notify patients before their preventive visit by posting signs on the exam room walls and the medical assistant provides a written notification for the patient to sign that they understand the billing policy. We are also trying to have the physician alert the patient, during the preventive medicine visit, when their concerns become a medical visit and may result in an out-of-pocket expense to the patient. Depending on the severity of the patient’s concern, the physician may be obligated to address the medical issue because, if he didn’t, it could result in a bad outcome for the patient. For example, if the patient states that they have been dizzy and having terrible headaches, this could mean that the patient may have a brain tumor or other significant medical issue. If the physician ignored this complaint, it would harm the patient or could harm others if the patient were driving a vehicle and had an episode. In addition, this would easily become a malpractice lawsuit against the physician.

Some physicians have chosen not to do both a preventive medicine visit and a problem visit on the same day. If the patient is scheduled for a wellness visit and a problem comes up, the physician would either make the decision to change the visit to a problem-oriented visit and reschedule the preventive if the problem is high risk; or have the patient return to deal with the problem issue at a later date if the problem is a low risk. This method keeps the appointments separate and easier for the patient to understand the difference. The downside is that it requires the patient to come back for a second visit, taking additional time off work, to deal with something that could have been handled during one visit.

I’d rather buy a month’s worth of Starbucks than…pay my doctor bill Wednesday, Jul 6 2011 

One of the biggest frustrations we have in the health care industry is due to patients not understanding their own health insurance benefits. Oftentimes, patients think that just because they carry insurance, that means that everything is covered and they don’t have to pay anything. Patients receive health care service and a month later they discover that their insurance doesn’t cover that particular service; however, instead of accepting the responsibility of paying, many patients fight, demand, and threaten the physician’s office staff to make the balance go away.

This phenomenon has gotten worse in the past twenty years or so. I subscribe to the theory that much of this mentality is due to the inception of HMO’s. In the beginning, HMO’s had either zero patient financial responsibility, or an exceptionally low out-of-pocket cost. People have been conditioned in thinking that health care is an entitlement. After about a decade, due to insurance companies (and employer groups) not being able to withstand the expense of higher utilization of “free” health care, they began to make the consumer more responsible by charging higher co-pays and not covering certain services. Unfortunately, most Americans expect the same Cadillac coverage without any additional expense (beyond their insurance premium and co-pay).

A major challenge in physician practices is to help their patient’s understand their insurance company’s reimbursement policies, all the while maintaining good will. Physicians are finding themselves having to develop various financial informed consent forms to assure that the patient understands that they may be responsible for some of the cost. Medicare has required this, in the form of Advanced Beneficiary Notices (ABN), for years.  Even so, we often hear patients state, “I signed it but didn’t read it.”  Or, “I was afraid if I didn’t sign it that I wouldn’t get the service.” Perhaps the days of accountability are long gone.

One of the biggest threats we hear from patients is that they will leave our practice if we don’t write off their balance. Not much that you can do about that. Health care is a business and we cannot pay the bills with altruism. In addition, it is fraud to bill the insurance company for services and write off the patient’s responsibility. Aside from financial hardship cases, routine adjustments of patient responsibility can get a physician excluded and/or fined by the government when it is a government program such as Medicare or Medicaid. Worst case scenario for commercial insurance is the insurance company dropping the physician from their network.

With lower reimbursements, practices really need to devote more energy in collecting all revenues due. The average overhead for a primary care physician practice is reaching 60%. There are no government subsidies for physicians, other than rural health care, community health care centers and native american health centers. More and more physicians are closing their offices, retiring early, selling their practices to hospitals, transitioning to concierge medicine, or going to cash only practices. This is devastating to primary care because of the physician shortage; however, many specialists are also getting hit hard as well.

New Trick by the Health Insurance Industry Tuesday, Nov 3 2009 

Imagine that you are an independent contractor for a company that pays you a specific rate for a specified amount of work; however, if you do more than the specified amount of work you would receive an additional amount.  Now, if you were to do that additional amount of work separately you would receive 100 dollars.  But, if you do that additional amount of on the same day as your normal work load, you would receive your normal pay for your normal work load and 50 dollars for the additional amount of work.  Would that be acceptable to you?

To illustrate further, I do my work and earn $100.   Tomorrow, I fill in for someone else and do their work and earn $100.  Okay, that seems fair. Tomorrow, I not only do I do my job, but I also completely do someone else’s work.  As an independent contractor, should I receive $100 for my normal work and that’s it?  Should I receive $200 for a double workload?  How about if I only get $150…$100 for my work and $50 for completing someone else’s job?  I think many of us would say that I should receive $200!

Unfortunately, many physicians are experiencing the $150 example from health plans when it comes to providing medical care on the same day as a preventive medicine visit.  According to universal coding principles, it is expected that a physician will code an evaluation and management (Office Visit) for diagnostic (medical) issues when done on the same day as a preventive medicine (complete physical).  One of the primary reasons is so insurance companies do not have to reimburse for services outside their reimbursement policies; for example, if the patient does not have preventive medicine benefits but comes in for a physical, the physical can not be coded as a covered medical benefit just to get  paid.

In physician coding, we are trained to code all services accurately to represent what actually was performed and documented so as to not open the practice up to the risk of fraud and abuse allegations.  In theory, one would think that if there is a universal coding policy, then the service should be reimbursed in a consistent manner; however, this is not the case.  What we are seeing is that the majority of health plans will pay the problem visit at 50% and the physical at 100% (there’s your $150!).  A few others will not reimburse the problem visit at all on the same day as the physical (you only get $100…double the work at the pay of one job!).  Consequently, many physicians are telling patients that they cannot have both services performed on the same day, thus the physician is able to get full reimbursement for each service (aha! that’s where I put my $200!).

It is inconvenient to the patient to make two appointments; but with the increasing expenses that physician’s practices are having to absorb, it is just not possible to throw away all or half of a reimbursement.  In addition, it is inconvenient to other patients who are not able to get in to be seen because of the physician’s full schedules…or doing in two visits that which he can do in one.  Understandably so!  The physician should be reimbursed for all of his services fairly.  This will allow the physician to be able see additional patients who require medical attention and not play insurance games!

7 Ways Health Reform Is Going to Affect You Thursday, Jun 11 2009 

U.S. News & World Report article

7 Ways Health Reform Is Going to Affect You


http://health.usnews.com/blogs/heart-to-heart/2009/06/10/7-ways-health-reform-is-going-to-affect-you.html