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Missing payments? No easy fix for unpaid out-of-network COVID claims

05/10/2021

A $6 million case concerning thousands of unpaid claims for COVID-19 testing and related services suggests that if you’re refused payment for services administered to out-of-network beneficiaries, you may be up a creek, despite laws that appear to protect your interests.

Master modifier 59: Scenarios, tips that go beyond the basics

05/10/2021

by: Susan E. Garrison

Ensure that your documentation can support modifier 59, used to describe a distinct procedural service, in order to steer clear of billing snafus. Remember that you should append modifier 59 to codes to identify procedures or services that are not usually payable when reported together.

Stay sharp: Feds’ health care enforcement is shifting — and expanding

05/10/2021

by: Marla Durben Hirsch

It’s time to reassess and update your practice’s compliance program. The government’s health care enforcement priorities are expected to shift with the new administration.

Here’s what the DOJ wants in an effective compliance program

05/10/2021

by: Marla Durben Hirsch

The HHS Office of Inspector General (OIG) has long established that a strong compliance program for physicians consists of seven elements:

New diagnosis? Try a corrected claim, but expect pushback from your MAC

05/10/2021

by: Roy Edroso

Question: We’ve had a claim denied on the basis of medical necessity because the provider’s original diagnosis was not covered. Now the provider, after further analysis, has determined that the actual issue is different from what she had originally thought and she wants to change her diagnosis and treatment. Can we resubmit the previous claim with the new diagnosis?

Modifier 59 claims return nearly $1.5 billion in Medicare payments

05/10/2021

by: Richard Scott

Mastering the use of modifiers can be lucrative business for physician practices, as the latest modifier 59 (Distinct procedural service) utilization numbers reveal. In 2019, providers pulled in nearly $1.5 billion from Medicare on thousands of codes paired with the modifier.

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