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:



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.


For Immediate Release: Monday, April 09, 2012
Contact: CMS Office of Public Affairs




The Department of Health and Human Services (HHS) today announced a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and   procedure codes (ICD-10).

The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement.   The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).   OESS is part of the Centers for Medicare & Medicaid Services (CMS).


On January 16, 2009, HHS published a final rule to adopt ICD-10 as the HIPAA standard code sets to replace the previously adopted ICD–9–codes for diagnosis and procedure codes (see HIPAA Administrative Simplification;  Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS,  74 FR 3328). The compliance date set by the final rule was October 1, 2013.

Implementation of ICD-10 will accommodate new procedures and diagnoses unaccounted for in the ICD-9 code set and allow for greater specificity of diagnosis-related groups and preventive services.  This transition will lead to improved accuracy in reimbursement for medical services, fraud detection, and historical claims and diagnoses analysis for the health care system.  Many researchers have published articles on the far-reaching positive effects of ICD-10 on quality issues, including use of specific reasons for patient non-compliance and detailed procedure information by degree of difficulty, among other benefits.

Some provider groups have expressed serious concerns about their ability to meet the October 1, 2013 compliance date.   Their concerns about the ICD-10 compliance date are based, in part, on implementation issues they have experienced meeting HHS’ compliance deadline for the Associated Standard Committee’s (ASC) X12 Version 5010 standards (Version 5010) for electronic health care transactions.  Compliance with Version 5010 is necessary prior to implementation of ICD-10.

All covered entities must transition to ICD-10 at the same time to ensure a smooth transition to the updated medical data code sets.   Failure of any one industry segment to achieve compliance with ICD-10 would negatively impact all other industry segments and result in rejected claims and provider payment delays.   HHS believes the change in the compliance date for ICD-10, as proposed in this rule, would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

Provisions of the proposed rule announced today

HHS is proposing to change the ICD-10 compliance date to October 1, 2014.

As stated, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement.

Standards compliance date

HHS proposes that covered entities must be in compliance with ICD-10 on October 1, 2014.

The proposed rule, CMS-0040-P, may be viewed at www.ofr.gov/inspection.aspx.

A news release on the proposed rule may be viewed at http://www.hhs.gov/news.

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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.

Gardasil (HPV Vaccine) approved for boys/young men Sunday, Aug 22 2010 

In the past several years, the FDA has approved new immunizations in an effort to prevent various illnesses, including sexually transmitted diseases that could result in cancer.  Once such vaccine, Gardasil, is “currently is approved for use in girls and women ages 9 through 26 for the prevention of cervical, vulvar and vaginal cancer caused by HPV types 16 and 18; precancerous lesions caused by types 6, 11, 16, and 18; and genital warts caused by types 6 and 11.”  In October 2009, the Food and Drug Administration announced that it approved the use of Gardasil vaccine for boys/men between the ages of 9 and 26 years of age, as well.

According to About.com, in providing Gardasil vaccines to young men, “the result would likely be:

  • less spreading of HPV
  • hopefully, fewer cases of cervical cancer in women
  • perhaps, a decrease in other types of cancer”

HPV can cause genital warts in men that may lead to several types of cancer, including oral, penile and anal cancers.

As with most new immunizations, it can take up to a year for this to process through to the insurance companies before they create policies to cover the vaccines.  At this point, Gardasil is covered by most health plans for girls and young women; however, the same is not true for boys and young men.  The Gardasil vaccine is quite expensive and requires a serious of three vaccines over a six month period that could cost in the range of $650-800 for the entire series.  It is recommended that you verify with your health plan, beforehand, whether or not they cover this vaccine, especially for the male gender.  If they do not cover this vaccine, it will result in the cost being transferred to patient responsibility.

FDA announcement:  http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm

About.com:  http://cancer.about.com/od/hpvvaccine/a/hpv_vaccine_boys.htm

Why is COBRA insurance so much money? Wednesday, Apr 14 2010 

stethoscope coiled like a cobra snake

Why is COBRA insurance so much money?

It seems that the general public has absolutely no understanding of what COBRA insurance is and why it costs so much.  You can read the “official” information outlining COBRA by visiting this link:


In “layman’s language”, COBRA is an extension of the insurance that a person had while they were employed.  The employee has group insurance through their employer. Typically, employers pass on some of the insurance premium to the employee while they are employed.  Historically, the vast majority of employers that provided insurance to their employees offset some of the premium as a benefit of employment, so the employee never actually realized the actual premium amount for the insurance coverage that he enjoyed.

Upon separation of employment, an employee is extended COBRA Continuation of Coverage; however, the employer passes the entire cost of the health insurance premium to the employee.  At the very most, the employer (or insurance company handling the COBRA requirements for the employer) can charge a 2% administration fee.

The fact is that health insurance premiums are very expensive.  If an employee only paid a nominal amount for their health benefits while they were employed, that just means that their employer paid a greater portion of the premium.  It’s unfortunate that the vast majority of employees don’t understand this concept, even after they receive their COBRA paperwork stating the total amount due for their health insurance.  Typically, people complain about the cost of COBRA as if they are being offered a completely different insurance that costs more than what they had.

No, folks, you are still enrolled in the very same health plan that you had while you were employed, but now you are responsible for the full premium and not your employer!

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!

Woman charged extra for asking doctor too many questions Saturday, Aug 8 2009 

Woman charged extra for asking doctor too many questions | 3 ON YOUR SIDE |
Arizona | azfamily.com

by Gary Harper/3 On Your Side

August 5, 2009

A Valley woman says she has a billing problem with her doctor’s office.

The billing problem has to do with a “well woman exam,” basically it is an annual physical for women.

The woman you are about to meet says it was supposed to be covered 100% by her insurance carrier, so why does she keep getting billed by the doctor’s office?

Shannon Karal, like a lot of women, knows the importance of having an annual physical. She says, “I do all my preventative visits for dentist, doctor, any of the normal things I try to go as much as they say you should go.”

So Shannon scheduled a well woman exam at a physician’s office called Doctors Goodman and Partridge, an exam she says that is 100% covered by her insurance carrier. Shannon explains, “I just had some questions and concerns about normal things that a young woman like me would have.”

Shannon says the exam was completely paid for by her insurance, however, she keeps getting a bill for $92 from the doctor’s office so, she called to find out why and, according to Shannon, she was told she asked too many questions during her exam.

She admits, “It makes me feel like next time I go to the doctor I shouldn’t share any of my questions or concerns or take any more time out of their day because I might be charged extra for that.”

Shannon maintains the questions she asked during her exam were all normal “female-related” questions and she cannot believe she would be charged. “I would completely understand this extra charge if there was another test done or something they do for my questions. But nothing! It was all verbal.”

The office of Doctors Goodman and Partridge would not talk to 3 On Your Side about Shannon’s case citing privacy issues but after our inquiry, they sent Shannon a letter saying, “The problems evaluated and managed at that visit were above and beyond the scope of a normal well woman exam” but, Shannon says that is nonsense and feels she is being billed for asking too many female-related questions, and taking up too much of the doctor’s time. Shannon tells 3TV, “I feel like there’s a stop watch every time I go to the doctor and they’re gonna be timing me and making sure I don’t go over that time and if I do then ‘Oh, there might be an additional charge for this.'”

Helped Patient Battle Health Plan and Won! Sunday, Jul 5 2009 

Just about a week ago, I received a call from a patient who was extremely upset that she was being billed $1,400.00 by the imaging facility for a CT scan after we told her that she did not need a prior authorization from her insurance company.  Typically, this is one of those things that it’s our word against the insurance company and, historically, the insurance company seems to always win.  I guess the axiom “he who holds the money has the power” applies in this kind of situation.  The insurance company insisted that they did not have a record of our phone call to them and that they would never have told us that this patient did not need a prior authorization for the CT scan.  The patient was irate and understandably so…especially with the economy the way it is.  As a goodwill gesture and to keep peace with the patient, I would have accepted the responsibility and paid for the scan and our office would be out the money.

But…we voice record all our incoming and outgoing telephone calls using a system called Talkument.  I have all of the staff and physicians trained on what information is helpful to me when I need to investigate a telephone conversation.  In this case, I pulled the patient’s chart and the medical assistant wrote a note stating that she called the health plan on 5/23/09 at 3:13 pm and found out that no prior authorization was needed and that she talked with Ann.  I knew my medical assistant’s extension and searched based on the information that I had, and viola, I found the four minute telephone conversation between my medical assistant and the health plan representative, Ann, who said that the patient did not need a prior authorization for the CT scan!

I had a three way conference call between the patient, myself and the health plan where I played the recording for them.  The patient was ecstatic!  I had to play this information a couple of levels up the ladder and was still told that someone would have to get back to me (quite frankly, I don’t think they were ready to address the fact that the doctor’s office actually had recorded them!  Uh oh!  They were caught!)

About a week later, the health plan representative called me and stated that they would cover the cost of this CT scan “this one time”.  She still did not want to take responsibility for her company giving inaccurate information.  She made it sound like we doctored up the recording…even though we have caller ID that had the health plan’s toll-free number and the first two minutes of the recording was the automated system that announces the health plan name.  I was even told by the rep that the person with whom my medical assistant had talked with, Ann, was not an employee of this health plan.  I love the lack of accountability!

Defensive medicine is taking on a new definition.  Besides the Internet, the next best resource I have in my office is the voice documentation system for phone call recording!  The system has aided me with staffing issues, patient issues and now insurance issues.  It has definitely paid for itself in protecting my physicians and our office from lying and deceit.

BLOG REVIEW: “Are Doctors Infected With The Stockholm Syndrome?” Saturday, May 2 2009 

A companion blog for The Yale Journal for Humanities in Medicine (http://yjhm.yale.edu)

Tuesday, February 17, 2009

Are Doctors Infected With The Stockholm Syndrome?

Medicare is a great social institution. It saves millions of people from financial destitution.

But many doctors feel unfairly treated by Medicare’s payment schedules. For the past two years Medicare has threatened to cut physician reimbursement by 10% in 2008 and by 20% in 2009. After an outcry from physicians, the cuts were eliminated and physicians were given increases of .5% and 1% respectively. Many physicians were relieved to see that the cuts were reduced and some groups including the AMA actually thanked the Medicare Payment Advisory Committee (MedPAC) for being so understanding.

But rather than thank Medicare for the tiny increases which some consider an insult, it would have been better if medicine’s leadership had preserved physicians’ honor and dignity by rejecting them outright.

This pattern of being threatened then given a small reprieve followed by thanking the oppressors bears great similarity to the so-called Stockholm Syndrome which Webster’s New World College Dictionary defines as a psychological state in which hostages sympathize or even become friendly with their captors.

When threatened by severe price cuts that seriously jeopardize their livelihoods doctors may not be kidnapped or locked in closets but they are hostages none the less. And thanking those who oppress them for being so understanding makes them victims of the Stockholm Syndrome.

Clearly, to go from a 20% cut to a 1% increase represents quite a difference in any physician’s income. But still, groveling before Medicare and thanking it for a puny 1% increase is wrong. This weak showing is sure to encourage private insurers to use the same strategy. By threatening to drop doctors from their lists for failure to conform to their standards for quality and cost-efficiency, private insurers will have another tool to control doctors. This control will become acute once electronic medical records are in place and every treatment, test, and consultation ordered by physicians will become instantaneously available to health insurers to see who conforms to their protocols and who doesn’t.

Far better for the future of medicine if its leadership had rejected Medicare’s 1% increase and dedicated the savings to lowering patients’ premiums.

Ed Volpintesta MD


My comment:

This is very true!  I think that this was premeditated by Medicare.  They knew physicians would not accept a small increase of 0.5% or 1%, so how do you get the health care industry to accept it?  Threaten a huge decrease in reimbursement and then come back at the 11th hour with the intended puny increase and act like you are doing physicians a favor…Medicare is a “hero”!  It’s crazy, but it has worked for years now.

Physicians are too busy to fight it because they have to see more and more patients to make ends meet.  So, the insurance companies, including Medicare, keep reimbursements low and physicians have to work harder, see more patients in an hour, and focus on documenting the notes to achieve adequate payment.  Now, we are seeing P4P…Pay for Performance…to get any further increases in reimbursement.  Sounds great right?  Is it really an increase?  I don’t think so.  To improve performance, the physician must reduce the number of patients seen and document more performance measures, which means their reimbursements will go down because they are not seeing as many patients as they did.  So, the increase will bring them up a bit IF they can prove that their performance measures are having a positive effect.  Sounds to me like the physician is working differently to receive the same amount of pay.

We are also looking at reimbursement incentives to implement Electronic Medical Records; however, this typically has made the physician slower and decreases the amount of patients that they can see in a day.  How is that effective for the bottom line?  The cost of EMR is extremely expensive.  In my practice of seven physicians, we are looking at over $100,000 to purchase an EMR.  How do we pay for it if we are seeing fewer patients each day?

Unfortunately, the government and insurance companies are developing regulations and policies without input or direct knowledge of how things actually work in a private practice.  In addition, there is no consistency between health plans, so it takes more employees to appeal denials and keep up with all the specific reimbursement policies.

Physicians in private practice are getting the life sucked out of them.  Insurance companies have created patient antagonism toward their physicians.  Society is pointing fingers at the cost of health care and implying that is the fault of the provider of services.  If that is the case, why do physicians make $100,000 to $300,000 a year, while insurance company executives make near a million or considerably more per year?  Why do the insurance premiums continually increase for both the patient and the employer, while the provider of service sees either flat or decreasing reimbursements?  Yet, insurance companies post health profits each quarter.
Charlene  Burgett, M.S.