According to President Obama’s healthcare reform provisions, an expected 40–50 million previously uninsured patients will be gaining healthcare access during the next 10 years.

The next 20 years could be thought of as the next great migration—when 77 million Americans, the biggest group ever, move through the window for ages 55–75. It’s the baby boomers and generation Xers getting older, bringing with them new challenges and pressures inside and outside the healthcare system.

Accuracy rules the day when it comes to submitting claims and avoiding denied claims. The simplest oversight on a claims submission can result in lost dollars, not just from the claim that isn’t paid, but also from the additional time and effort expended by staff.

It seems like an unwinnable game of cops and robbers. Physicians demand to be compensated for ED call, and the hospital refuses to meet those demands because it will eat the bottom line. Physicians retort with threats to cease providing service if the hospital does not meet their demands, and the hospital shoots back with threats to employ physicians, thus creating competition with independent members of the medical staff. 

Your Medicare payments won't drop 23% on Dec. 1 under a Senate-approved bill. The Senate adopted a one-month delay, which means you're still facing a devastating double-digit drop on Jan. 1. On Thursday, the Senate approved $1 billion to cover the month-long delay of payment cuts. Amendments also include reducing the multiple procedure payment reduction (MPPR) that will be applied to therapy services to 20% instead of 25% (NPP Report 11/22/10).

Your Medicare payments are still in jeopardy. Congress returned to Washington on Nov. 15 after mid-term elections and had not put forth a bill to fix the broken Medicare payment formula as Part B News went to press. A 23% cut will reduce your Medicare reimbursements if lawmakers fail to act by Dec. 1. Another cut, set for Jan. 1, would drop payments by 30% when compared to current rates.

You still don't know whether your Medicare payments will fall 23% in three weeks as a lame-duck Congress wraps up its term (see related story). Whether the massive pay cut will hit remains uncertain, but you can bet on Medicare payments staying flat at best, experts say.

Be on the lookout for clauses in your managed care contracts that require you to accept from the payer the lowest rate you give any other payer. These provisions, known as most favored nation (MFN), cost-containment or prudent buyer clauses, restrict your ability to contract with other payers and force you to get paid less - sometimes a lot less - than you had originally agreed to when you signed the contract.

You stand to earn up to $174.78 for every single Medicare patient whose a member of your practice next year, and $116.52 for them every year afterward (assuming there is no pay cut) - all thanks to the annual wellness visit (AWV). Your providers will have to perform one additional element during the visit to earn the money, but they'll also be able to bill related preventive services more efficiently because of changes in the final 2011 Physician Fee Schedule (PFS).

A practice inadvertently submits G8553 (at least one prescription created during the encounter was generated and transmitted electronically using a qualified electronic prescribing system) on claims during the 2010 E-prescribing Incentive Program year. The practice later discovers it did not have the required certified or qualified e-prescribing system. What do you do next?