Utilize two timely claims filing extensions when CMS corrects an error or creates a retroactive entitlement benefit for a patient. CMS has revised its 12-month timely claims filing requirement (PBN 4/15/10). Transmittal 2140 carves out exceptions and provides additional information about the rule requiring you to submit a claim within 12-months from the date of service. A claim submitted more than 12 months after the date of service will be denied.

Most physicians and non-physician practitioners (NPPs) at your practice will be subject to “limited” screening when enrolling in the Medicare program. But CMS has lumped physical therapy providers and physical therapy groups into a category with more intense screening measures.

These charts offer a rare look at the success of appeals within Medicare Advantage (MA) plans, which do not often share their claims or appeals data with the public, unlike CMS. The first graph shows the percent of reconsiderations (second-level appeals) in which the MA plan’s decision was overturned (either partially or completely) or upheld (this also includes appeals that were dismissed). NOTE: All data comes from Maximus Federal Services Inc., a private contractor selected by CMS to act as the national independent review entity with oversight on MA denials. NOTE: Maximus only processes second-level appeals and does not have code-level data, a company official tells Part B News. The second graph shows the dollar amounts involved; all the data is from 2009.
 

We are a gastroenterology office and at times bill the tobacco cessation counseling visit code (99406). We don’t want to step on the primary care’s toes with respect to billing for tobacco counseling. Is it typically paid once per year for any physician? One time per patient, period?

A new CMS article explains how the agency’s auditors decide whether inpatient status was justified. CMS released the article as a response to provider concerns over how CMS, its carriers and various auditing groups utilize screening criteria to analyze documentation and make medical necessity determinations.

In a room at Texas Health Harris Methodist Hospital Hurst-Euless-Bedford, 12 patients and 12 OB/GYNs sat paired at tables. The physicians described their practices and specialty areas and the patients explained their situations and discussed what they were looking for in a doctor. After five minutes, the patients rotate and begin another conversation with the next physician.

The managed care portfolio of contracts, once comprising insurance carriers with commercial members enrolled in HMO and preferred provider organization products, has expanded to include managed Medicaid, Medicare Advantage, Medicare private fee-for-service, and TRICARE plans.

An independent practice association (IPA) can seem like a good option for practices looking to improve their revenue potential, but experts caution that you must be careful with structuring an IPA to avoid running afoul of antitrust laws.

In this 24/7 work world, it seems healthcare professionals are working nonstop. For surgeons, there are added concerns that the exceedingly long shifts have a potential effect on patient care stemming from psychological trouble spots: burnout, depression, career dissatisfaction, and problems at home.

Now that healthcare reform has gone from a concept to a law, big changes are ahead for everyone associated with providing healthcare to Americans. But perhaps no other group will need to adapt more than physicians, many of whom fear that their independence will be curtailed and their influence will retreat. Coupled with that fear is the belief that patients will suffer as the “art” of medicine is replaced by standardization.