Medicare: The Government – Your Biggest Payer, Part 1

Medicare: The Government – Your Biggest Payer, Part 1

Clinicians will contract with many commercial insurance providers during their careers, but the heavy hitters of reimbursements are government-backed insurance plans.

In this informative two-part series, Nitin Chhoda examines programs operated by the federal government and what practitioners should know about them.

MedicareGovernment-operated healthcare programs encompass Medicare, Medicaid, Workers’ Compensation, CHAMPUS and Tricare.

Of all the government-run insurance plans, Medicare is the largest and is comprised of four types of coverage, Part A, B, C and D.

Participation is mandatory for some portions and voluntary for others, leading to confusion for patients.

Congress dictates how Medicare claims are paid. Reimbursement requests must be submitted within a specified time frame and the agency prefers to pay providers via electronic fund transfer.

It’s critical for practitioners to verify which Medicare elements a client participates in before services are rendered.

Medicare Part A

The first part of Medicare coverage pays for inpatient care in hospitals, skilled nursing facilities, home healthcare and hospice, but an overnight stay in a hospital is no guarantee of payment. Clients must meet specific requirements for Medicare to pay for inpatient services.

Medicare Part B

The B portion of Medicare coverage is designed to pay for services, treatments and procedures that are medically necessary. Included are services by physicians, home health services, durable medical equipment and outpatient visits. Some preventative measures are covered, including vaccines.

Part B is optional, but those who don’t enroll according to government guidelines are penalized. Patients often believe they’re automatically enrolled when they retire and are dismayed to discover they have no coverage. Recipients also have an annual deductible and pay a 20 percent copay for services.

Medicare Part C

Part C, also known as Medicare Advantage, is an insurance replacement plan offered by private companies that have been Medicare approved. Part C is favored by individuals who prefer private insurance coverage. Depending on the provider, plans can require beneficiaries to pay out-of-pocket expenses, obtain referrals, and only see network providers.

Replacement plans can be used to cover Part A and B services, and some plans include medication and vision coverage. To avoid medical billing reimbursement difficulties and appeals, always verify the client’s coverage, restrictions and limitations prior to treatment, along with the plan’s fee schedule to determine if it differs from Medicare standards.

Medicare Part D

The Medicare prescription drug plan is Part D. While Part D coverage doesn’t typically cause a problem for medical professionals, a large number of Part D recipients mistakenly believe they’ve enrolled in a Medicare supplement policy. Practitioners may find they’re spending a significant amount of time explaining the difference to their patients.

Medicare Supplement Plans

Patients can enroll in a Medicare supplement program, also known as Medigap plans, to cover the costs that Medicare doesn’t pay. It provides a source of secondary coverage, but doesn’t include any non-approved Medicare expenses. Always verify secondary coverage prior to any patient encounter.

Medicare coverageMore than 50 million people age 65 or older and younger individuals with disabilities have some type of Medicare coverage.

It represents a large population of patients upon which practitioners can draw that are covered by a reliable payer.

Incentive payments may also be available for clinicians practicing in geographic areas with a demonstrated shortage of medical professionals.

How an EMR Can Lead to Your Personal Freedom

How an EMR Can Lead to Your Personal Freedom

Implementing the EMR technology is essential in the 21st century for clinicians to convert to digital records, submit reimbursement claims and get paid.

EMR expert, Nitin Chhoda, was one of the first to use the software and is sharing his expertise on the many ways an EMR contributes to a practitioner’s personal freedom.

EMRTime is money and an EMR provides savings for clinicians on both fronts.

Verifying Insurance Coverage

From the moment a client makes an appointment to the moment the patient encounter is completed, an EMR is on the job, increasing efficiency and boosting productivity.

An EMR has the tools to verify insurance information prior to the client’s visit, providing practitioners with the information needed to formulate a treatment plan based on insurance limitations, coverage and eligibility.

Fewer Hours and More Money

A fully integrated EMR includes a secure patient portal where individuals can complete a health history online. That information is available prior to the client’s visit, allowing clinicians to familiarize themselves with the patient’s problems before they arrive. The data can decrease the wait times for patients and practice owners by up to 47 percent and reduces time spent gathering information in the exam room.

The information gathered with an EMR allows practice owners to see more patients during the normal work day and manage treatment options, without the need to stay late or conduct extended hours.

Clinicians have more free time and the funds to enjoy personal activities with friends and family.

Anytime Access

Patient records are updated instantly with an EMR, anytime the client’s information is retrieved. The systems provide a single resource for all aspects of a practice’s management needs. The records can be accessed from multiple locations and by numerous medical professionals to coordinate care.

If a patient requires treatment in an ER, the on-call physician has all the information needed to assess and treat the patient, without the need to contact the client’s physician.

Space and Time

Office supplies represent a major expense for practices. An EMR saves everything digitally, eliminating the need for paper documents, files, folders and all the related products needed to manage a mountain of paperwork.

EMRs require a fraction of the space needed for file cabinets to house paper records. There’s no need to search and sift through dozens of documents to locate a specific paper and the technology eliminates misplaced files.

Errors and Reimbursementselectronic medical records

With an EMR, reimbursement claims are submitted electronically, in real time. The technology contains the ability to identify errors, mistakes and potential difficulties with claims before they’re transmitted.

A complete record of each transaction is maintained, along with patient balances, and payments can be received in as little as 10 days.

Electronic medical record provides the tools for clinicians to work smarter, not harder. They save time through increased efficiency and productivity within all departments, and work to identify errors and mistakes that can virtually eliminate denials and rejections. The result is that clinicians have increased revenues and the freedom to reap the benefits of their labor.

Reimbursement Using EMR System — The Secret to a Low-Delay Claims

Reimbursement Using EMR System — The Secret to a Low-Delay Claims

As insurance companies scrutinize reimbursement submissions more closely, clinicians are enduring longer turnaround times to collect money on claims.

The simple installation of an integrated EMR can transform those extended waits for funds into a low-delay reimbursement system and Nitin Chhoda explains it here, in this article.

reimbursementEMRs enable faster reimbursements and can detect claims with potential problems before they’re submitted, virtually eliminating denials.

The majority of denials and contestations can be traced to simple human errors in data entry and by preventable problems that can be avoided by verifying a client’s insurance coverage before services are rendered.

An integrated electronic medical record submits claims electronically to arrive almost instantaneously at the intended destination and can detect an extensive array of errors and notify practitioners prior to submission.

Human Data Entry Mistakes an EMR Can Help Avoid

Mismatched, incorrect procedure codes and improper patient information that doesn’t reflect the information for the client’s complaint is a common cause of denials. An example would be listing a procedure for a male when the client is female.

Each insurance provider has its own set of rules for reimbursement submissions. That includes specific claim forms. An infraction results in an automatic denial until the correct forms are submitted.

Health insurance providers are requesting prior authorization for an increasing number of treatments and procedures. If the clinic fails to obtain authorization, the insurance company can refuse to pay clinicians anything.

It happens infrequently, but a patient may need to see their healthcare professional twice in the same day to receive the same or similar treatments. Practitioners encounter difficulties when submitting these types of claims. Insurance companies view this as a duplicate reimbursement request and will reject it automatically.

It would seem like common sense, but clinicians who don’t file reimbursement claims in a timely manner will forfeit payment. Practitioners have one year to file their claim and such oversights can cost clinics thousands of dollars.

Check the Facts Before Treatment Begins

In a time of high unemployment and loss of benefits, it’s essential for practices to verify insurance coverage and client information before the patient ever reaches the clinic. An EMR provides the means to accomplish these and other tasks with alacrity, reimbursement claims included.

Insurance coverage that has lapsed, been terminated, wasn’t in force when the patient received services, and clients not eligible for coverage represent a major reimbursement problem for practitioners. All of that information can be ascertained easily prior to the patient’s appointment.

Many healthcare insurance providers are offering basic or minimal services and few patients understand their coverage or limitations. It’s imperative that clinicians determine the type of treatments covered under each insurance plan.

What constitutes a reasonable fee for practitioners and insurance companies varies widely. Each insurer has its own guidelines on the amount that can be reimbursed for specific treatments and reimbursement claims that exceed which will be rejected for unreasonable fees.

reimbursement claimsClinicians and insurers also differ on procedures. Ordering a CT scan instead of a less expensive x-ray can result in a determination of not medically necessary by the insurance company and loss of income for the practitioner.

An EMR represents the best solution for a low-delay reimbursement system. It has the tools to identify an extensive array of human errors that will delay or prevent claim payments.

An integrated EMR is the key to verifying patient information and insurance coverage to ensure practitioners receive the reimbursement to which they’re entitled.

Claim Appeals 101

Claim Appeals 101

Reimbursement claims can be denied at any time and for any number of reasons. Most problems can be remedied easily, but when talking fails to facilitate a desirable outcome it may be necessary to file an appeal. In this revealing article, Nitin Chhoda addresses the basics of filing an appeal.

clearinghouseMost appeals in the billing process, physical therapy billing included. will involve commercial insurance companies.

How a clinician approaches an appeal has a huge impact on how quickly and smoothly the process is concluded.

Unfortunately, the onus is on the practitioner to prove why a claim wasn’t processed properly for payment. That requires knowledge of the payer and the terms of the contract that was signed with the insurance provider.

Provider Relations

Many contracts include a prompt pay clause that can cost the payer fees and interest on late payments if they didn’t file or process the claim according to the terms of the contract. The first point of contact when filing an appeal will usually be provider relations to ascertain if the claim was received and how it was processed.

A phone call can be all that’s needed to quickly remedy the situation. Some payers provide online reconsideration forms that can be submitted, while others require a formal written appeal. It’s critical to maintain complete documentation of all verbal and written communication associated with the appeals process.

Provider Representative

If the claim wasn’t processed due to the contract loading incorrectly in the payer’s software system, the next step is to speak with the provider representative. This individual is charged with ensuring the contract between the medical provider and payer is correct and loaded in the claims processing software system.

Expect to be vetted and answer specific questions about the claim. The provider representative may be able to locate the problem and solve it.

Representatives also have the power to send the claim back to the payer for reprocessing.

Written Appeals

If a phone call fails to resolve the issue, a written appeal must be submitted. It should include all the pertinent information about the claim and clearly state the expected outcome for settlement. Explain why the actions are being sought and further steps that will be taken, such as referring the matter to the practice’s attorney.

Exercise Control

Appealing a claim rejection is time consuming and frustrating. It’s critical to exercise control and professionalism at all times. claim submission

The appeals process relies on facts for resolution and it’s important to clearly state the problem and the payment expected. Refer to specific clauses in the contract to prove points.

A denied or rejected claim delays payment and appealing the decision can require considerable time and effort.

The process is sometimes necessary to collect the fees to which clinicians are entitled and it’s important to keep a cool head throughout the process.

Most disputes with commercial payers can be solved if practitioners approach the situation armed with the facts and the terms of the payer contract.

Insurance: The Rules, Regs and Who Makes the Decisions

Insurance: The Rules, Regs and Who Makes the Decisions

The rules governing healthcare insurance procedures are as varied as the companies that offer policies. Payers may choose to follow the same regulations as government backed insurance plans, while others have developed their own unique set of parameters.

It’s essential for billers to be familiar with them all and electronic medical record expert (EMR), Nitin Chhoda, has released new data on who makes the rules that govern reimbursements.

insuranceWho Controls The Purse Strings?
When it comes to clinicians being reimbursed for the services they render, practitioners should never forget that insurance companies are firmly in control of the entire process.

Each payer has its own set of policies, procedures, manuals and submission requirements. The payer establishes the rules and regulations that medical billers and coders must follow to ensure clinicians are reimbursed.

Practitioners typically contract with commercial insurance companies to reimburse them when one of their covered clients seeks medical attention. Most individuals have insurance through their employer and the payer underwrites the plan, complete with financial caps, treatment limitations and the need for prior authorization and referrals.

Networking Opportunities
Insurance companies control access to providers through the employment of networks. The insurance company maintains a network of medical providers with which it has a contract. The arrangement ensures a steady stream of patients for practitioners.

In return, the clinician agrees to receive specific reimbursements for services to limit outlays by the insurance company.

Contract Specifics
Contracts define time limits for submitting claims, how long the insurance company has to pay the claim, and the type of plans included in the agreement. Fee schedules, procedures that require preauthorization or referrals, and the appeals process are clearly spelled out.

Other payers choose to adhere to the fee schedule set forth by Medicare, modify the fees to pay 110 to 125 percent of what Medicare reimburses, or even pay less. Even though the medical provider may receive less than the Medicare fee, insurance company executives know that patients covered under their plans represent a substantial client base.

The Path to Payment
Most claims result in prompt payment, but the potential always exists for the payer to repudiate a reimbursement. Practitioners must use caution when negotiating contracts with payers, be cognizant of the terms, and long-term implications. Appeals can be filed when necessary.

Much of the reimbursement process relies upon the medical billing and coding specialist entering the correct codes, and ensuring documentation complies with the payer’s submission specifications.

insurance guidelines

Payer-practitioner contracts should be loaded in the practice’s EMR software to facilitate clean claims.

Insurance companies call all the shots when it comes to reimbursements. Clinicians must be vigilant when negotiating contracts with payers to ensure they’re receiving the best return for their services.

A great many payers exist, each with its own set of rules, regulations and requirements, but with a good billing and coding department, participating in a network of insurance providers can be a good investment for the practice.

Medical Payer : Who Is It and Who Has the Money? Part 2

Medical Payer : Who Is It and Who Has the Money? Part 2

Most patients have a commercial healthcare insurance plan that pays a portion of the cost should they become ill or require medical attention.

Commercial plans account for the bulk of a practitioner’s reimbursements, but an extensive array of government operated insurance plans are available that offer an added source of revenue.

Nitin Chhoda wraps up his two-part series on medical payers with a look at government-funded healthcare insurance.

medicalThe federal government sponsors an array of healthcare insurance medical programs for military personnel and their dependents, the elderly and disabled, low-income individuals, and employees that are injured at work.

Originating at the federal level, some programs are administered by individual states or through regional contractors.

Medicare
The largest government operated insurance plan is Medicare, serving the disabled and those 65 or older. It’s essential for practitioner to verify a patient’s Medicare coverage.  Medicare is confusing to medical clients and many mistakenly believe they’re enrolled for services when they’re not.

Medicare prefers to pay providers via electronic fund transfer and most claims are paid without problem when submitted correctly. Use electronic medical record technology whenever possible to facilitate the payment process. Medicare is comprised of four components.
•    Part A – Pays for home healthcare, hospice, in-patient hospital stays and skilled nursing facilities.
•    Part B – is optional and pays for medically necessary services.
•    Part C – is a replacement plan for employer-based policies that allows individuals to enroll in a private healthcare plan if they desire.
•    Part D – covers prescriptions.

Medicaid
For low-income individuals and some Medicare recipients, Medicaid assists by paying all or a portion of their medical bills. The program follows federal regulations, but may be administered by private healthcare companies. Practitioners may find it difficult to verify a patient’s eligibility status and Medicaid maintains a fee schedule that’s not negotiable.

Tricare
Funded by the Department of Defense, Tricare is used by active military personnel and their dependents. Coverage is separated into three parts to address the different healthcare needs of the individual.

The medical plan pays a set amount and practitioners are expected to accept that amount as full payment, without billing patients for the difference.

•    Tricare Standard – is used by active, reserve and retired military personnel, and eligible family members.
•    Tricare Prime – serves the same individuals as Tricare Standard, but requires members to seek treatment from network providers only.
•    Tricare for Life – is a supplement for former Tricare members who are eligible for Medicare.

CHAMPUS VA
The Civilian Health and Medical Program of the Uniformed Services provide coverage for VA patients who don’t qualify for Tricare, along with spouses and children of veterans disabled or killed in the line of duty. CHAMPUS works much like an HMO, and requires referrals and prior authorizations.

Workers’ Compensation
Employees who have been injured or disabled on the job, or acquired an occupation-related disease, are eligible for Workers’ Compensation. Providers must enroll and be assigned a Department of Labor number. Medical services must be medically necessary and receive prior authorization. Clinicians of healthcare practice management must ensure all procedures are reported and have a verified diagnosis code from Workers’ Compensation.

Medical records must be included with the reimbursement claim and practitioners must provide regular follow ups. Even then, clinicians aren’t guaranteed payment, which is distributed according to a pre-determined fee schedule.

medical payersPayments are made via electronic fund transfer. Workers’ Comp claims are submitted to one of three divisions – Federal Employees’ Compensation, Division of Coal Mine Workers’ Compensation and Division of Energy Employees.

Government-funded healthcare plans offer practitioners additional source of revenues, but claims must adhere to the strict standards set forth for each program. Filing a medical claim can be a time consuming process, but can be facilitated through the use of an EMR to ensure accuracy and timely reimbursements.