A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis. CMS develops fee schedules for physicians, ambulance services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies.
You can find Fee Schedule downloads, links, and more information at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html
Work Cited: cms.gov
Thursday, October 15, 2015
MEDICARE
CMS the Center for Medicare and Medicaid Services has a Website which provides information on Medicare and Medicaid Services. https://www.cms.gov/Medicare/Medicare.html
You can find links for:
You can find links for:
- General Information
- Appeals & Grievances
- Billing
- Coding
- CMS Forms
- Audits
- Coordination of Benefits & Recovery
- Coverage
- E-Health
- Eligibility & Enrollment
- End-Stage Renal Disease
- Fraud & Abuse
- Health Plans
- Medicare Advantage
- Medicare Contracting
- Medicare Fee-for-Service
- Prescription Drug Coverage
- Prevention
- Provider Enrollment & Certification
- Quality Initiatives/Patient Assessment Instruments
- Provider Types
- Special Topics
YouTube on Medicare and the CMS-1500
I found these YouTube videos on Medicare informative. I also included some videos on the CMS-1500 Claim Form, and other videos I found helpful.
- Cheryl Bradley lectures on Medicare Billing - http://www.youtube.com/watch?v=7uD9KdBkCjs
- Introduction to Medicare - Claims Data: Source and Processing - http://www.youtube.com/watch?v=BPyoN7-tDzs
- Medicare Billing Guidelines | Medicare Parts A, B, C and D - https://www.youtube.com/watch?v=Jvi4eBDkrQw
- Jo Moore CMS1500 Claim Form Tutorial - https://www.youtube.com/watch?v=U7-p98JbFvg
- Electronic CMS-1500 Claim Form filled out for Medicare - https://www.youtube.com/watch?v=YXvUkeSvGfY
- WoundRounds on Demand Webinar: Medicare Part B Billing for Wound Care Supplies: A Practical Guide - https://www.youtube.com/watch?v=5eVyTaE6qSY
- Medical Billing:- Medicare as Primary Insurance - https://www.youtube.com/watch?v=v6Mx81Xi6o4
Tuesday, October 6, 2015
The Blue Plans, Private Insurance, and Managed Care Plans
You should always check the patients insurance card to find out key information about the specific insurance they have. Make a photocopy of both the front and the back of the card. You will use this information when billing, making inquiries, and authorizations. Every medical practice should have available the current provider manuals for every insurance carrier it is contracted with, including its state's Blue Cross/Blue Shield Plans. To discover silent PPOs, always pre-certify procedures, and look at patients' insurance card even if the patients are established. Keep on hand an alphabetic list and profile of all plans with which the practice has a signed contract. Always be aware of preauthorization requirements. If a managed care plan refuses to authorize payment for a recommended treatment, tests, or procedures, have the PCP send a letter to the plan, include medical documentation, such as office visit notes, lab reports, and x-ray reports, to support the insurance claim. When a referral authorization form is received, make a copy of the form for each approved office visit, laboratory test, or series of treatments. Then use the form as a reference to bill for the service. To create a managed care plan reference guide make a grid. Use a sheet of paper, and list each plan with the billing address vertically in a column to the left. Then list significant date horizontally across the top. Suggested titles for column categories are as follows: eligibility telephone numbers, copayment amounts, preauthorization requirements, restrictions on tests frequently ordered, participating laboratories, participating hospitals, and the contract's time limit for promised payment. Referring to this grid can provide specifics at a glance about each plan's coverage and copayment amounts. Keep this information in a three ring binder. A good procedure is to include this information on each patient's data sheet when benefits are verified.
KEY POINTS:
KEY POINTS:
·
Providers must be contracted with Blue
Cross/Blue Shield to receive payment as a member physician. Patients may have a
traditional fee-for-service or one of many types of managed care plans. Plan benefits
and coverage, as well as deductibles and copayments, vary.
·
Managed care plans are prepayment health care
programs in which a specified set of health benefits are provided in exchange
for a yearly fee or fixed periodic payments to the provider of service.
Patients join the plan and pay monthly medical insurance premiums individually
or though their employer. Patients pay a small copayment and sometimes a
deductible for medical services.
·
Primary care physicians (PCPs) act as gatekeepers
who control patient access to specialists and diagnostic testing services.
·
Health maintenance organizations (HMOs) have
models, such as prepaid group practice model, staff model, network HMO, and
direct contract model.
·
The Patient Protection and Affordable Care Act
(the Affordable Care Act), and H.R. 4872, the Health Care Reconciliation Act)
have provisions which include the following: forbids insurers form canceling
insurance coverage (rescission), eliminates preexisting condition exclusions,
ends lifetime limits on benefits, gives tax credits to small businesses that
offer coverage, provides temporary insurance until 2014 for people who have
been denied because of their health status, allows young people to remain on
their parents’ insurance until age 26, requires insurers to use a high
percentage of premiums for benefits instead of profits or overhead, makes some
preventive measures free, and almost everyone is required to be insured or they
will pay a fine.
·
Types of managed care plans are the exclusive
provider organization (EPO), foundation for medical care (FMC), independent (or
individual) practice association (IPA), preferred provider organization (PPO),
silent PPO, physician provider group (PPG), point-of-service (POS) plan,
triple-option health plan, provider-sponsored organization (PSO), and religious
fraternal benefit society (RFBS).
·
Managed care plans, such as employee benefit
plans (EBPs) purchased by employers, must comply with the federal regulations
of Employee Retirement Income Security Act (ERISA) and do not fall under state
laws.
·
The Quality Improvement Organization (QIO)
program (formerly the peer review organization) evaluates cases to determine
appropriateness, medical necessity, and quality care.
·
Utilization review (UR) is a process bases on
established criteria for evaluating and controlling the medical necessity of
services and providers’ use of medical care resources to curb expenditures.
·
Some managed care plans may require prior
approval for certain medical services or referral of a patient to a specialist.
Four types of referrals are formal
referral, direct referral, verbal referral, and self-referral.
·
If a contract has a stop-loss limit, it means
that the provider can begin asking the patient to pay the fee for the service
when the patient’s services are more than a specific amount.
·
A managed care plan that has a withhold
provision may retain a percentage of the monthly capitation payment or a
percentage of the allowable charges to physicians until the end of the year to
cover operating expenses.
*find links to resources on The Internet Resource tab.
Thursday, October 1, 2015
Office and Insurance Collection Strategies
Common Collection Methods:
- Be diligent in the insurance claim process
- Collect payment at time of service
- Monthly statements
- Telephone calls
- Past due / 10 day notice
- Collection agencies
- Small claims court - as a last resort!
American Medical Billing Association - AMBA Sponsors a certification examination for Certified Medical Reimbursement Specialist (CMRS).
Appeal Solutions Appeal software company.
Bankruptcy Information site from the American Bar Association.
Fair and Accurate Credit Transactions (FACT) Act Full-text online document from the United States Department of the Treasury.
Fair Credit Report Laws Includes information on FACTA - the Fair and Accurate Credit Transactions Act.
Fair Credit Reporting Act Information and additional links from the Federal Trade Commission, Fair Credit Reporting Act complete text.
Fair Debt Collection Practices Act Information and additional links from the Federal Trade Commission.
Medicare Health Plans Includes information on Medicare Managed Care Appeals & Grievances; from the Centers for Medicare and Medicaid Services.
Nolo Commercial provider of legal information for consumers and small businesses.
Prompt Pay Statutes by State A downloadable document with information on specific states. One of several tools available online from Karen Zupko & Associates, Inc.
Small Claims Court.com "How to file in small claims court with free court forms and in-depth information about garnishment and judgment collection actions!" From Rich's Enterprises, L.L.C.
Uniform Commercial Code Locator Site from the Legal Information Institute, Cornell University Law School.
Journals
Family Practice Management From the American Academy of Family Physicians. While this is a medical title, it contains many useful items related to professional office practices.
Medical Economics Open-access online, includes information on collections.
Resources for Locating People
Anywho Skip tracing resources, Anywho Reverse Directory.
Bigfoot Site includes a PeopleSearch option.
InfoSpace Skip tracing resources.
InfoUSA Skip tracing resources.
Search Bug Skip tracing resources.
Switchboard.com Skip tracing resources.
WhoWhere? Skip tracing resources from Lycos.
Yahoo People Search Skip tracing resources.
Recieving Payments
- Payment from a third-party payer after submission of a paper claim should occur within 4 to 12 weeks, and for an electronic claim it should occur within 7 days. When a payment problem develops and the insurance company is slow, ignored, denies, or exceeds time limits, contact the third-party payer.
- An explanation of benefits (EOB) or electronic remittance advice (RA) should be read and interpreted line-by-line, checked to establish whether the amount paid is correct, and amounts posted to each patient's financial account.
Internet Resources for Receiving Payments
Receiving Payments and Insurance Problem-Solving
Finance Information Center: Billing / Coding / Reimbursement Online resources from HCPro A "provider of integrated information, education, training, and consulting products and services in the vital areas of healthcare regulation and compliance."
Your Guide to Medicare Medical Savings Accounts (MSA) Plans The official government booklet from Centers for Medicare and Medicaid Services.
The Official U.S. Government Site for Medicare Information Includes a glossary of terms.
QuickBooks Support Site Includes online videos for troubleshooting problems.
Journals
Appeal Letters Online Online newsletter for regulatory information on appeals, from the commercial site Appeal Solutions.
Agencies, Organizations and Associations
American Bankers Association There is also an online site for the ABA Banking Journal Online.
American Medical Billing Association - AMBA Sponsors a certification examination for Certified Medical Reimbursement Specialist (CMRS).
NDCLytec Commercial company for practice management and billing software.
Thursday, September 24, 2015
Special Guidlines for Claim Forms
Here are links to special guidelines for claim forms both electronic and paper:
Blue Cross Blue Shield
https://www.blueshieldca.com/provider/claims/policies-guidelines/special.sp
Tricare
http://www.tricare.mil/Resources/Claims/MedicalClaims/CompletingClaimForm.aspx
Worker's Compensation
http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Blue Cross Blue Shield
https://www.blueshieldca.com/provider/claims/policies-guidelines/special.sp
Tricare
http://www.tricare.mil/Resources/Claims/MedicalClaims/CompletingClaimForm.aspx
Worker's Compensation
http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Electronic Claims
Do's and Don'ts of Electronic Claims
Do: Use the patient account numbers to differentiate between patients with similar names.
Do: Use correct numeric locations of service code, current valid CPT, of HCPCS procedure codes.
Do: Print an insurance billing worksheet or perform a front-end edit (online error checking) to look for and correct all errors before the claim is transmitted to the third-party payer.
Do: Request electronic-error reports from the third-party payer to make corrections to the system.
Do: Obtain and cross-check the electronic status report against all claims transmitted.
Don't: Bill codes using modifier -22 electronically unless the carrier receives documents (called attachments) to justify more payment.
Internet Resources for Electronic Claims
Do: Use the patient account numbers to differentiate between patients with similar names.
Do: Use correct numeric locations of service code, current valid CPT, of HCPCS procedure codes.
Do: Print an insurance billing worksheet or perform a front-end edit (online error checking) to look for and correct all errors before the claim is transmitted to the third-party payer.
Do: Request electronic-error reports from the third-party payer to make corrections to the system.
Do: Obtain and cross-check the electronic status report against all claims transmitted.
Don't: Bill codes using modifier -22 electronically unless the carrier receives documents (called attachments) to justify more payment.
Internet Resources for Electronic Claims
AAFP's Center for Health Information Technology and resources from the Practice Management site of the American Academy of Family Physicians.
Coding Gateway site to many resources from the American Health Information Management Association (AHIMA).
HIPAA Administrative Simplification Enforcement Tool Available online from the Centers for Medicare and Medicaid Services - CMS.
TRICARE Providers Site includes billing information.
Workers' Compensation related links From the North Carolina Industrial Commission, maintained by Robert W. McDowell.
Journals
Advance for Health Information Professionals Biweekly magazine for health professionals.
CIO Magazine In addition to online articles, contains an extensive set of links to other web resources.
Federal Register Available online from the Government Printing Office.
Healthcare Informatics Online Includes a section on Financial issues, including coding and payment systems.
Healthcare IT News Covers technology and the business of health care.
Journal of the American Health Information Management Association Selected articles are available online.
Agencies, Organizations and Associations
North Carolina Healthcare Information and Communications Alliance, Inc. - NCHICA A "nonprofit consortium of over 200 organizations dedicated to improving healthcare by accelerating the adoption of information technology."
Office of Inspector General, Department of Health and Human Services.
VeriSign Online security services.
Workgroup for Electronic Data Interchange - WEDI A membership organization promoting health related electronic commerce.
Paper Claims CMS-1500 (02-12)
Do's and Don'ts of Paper Claims
Do: Use original claim forms printed in red ink; photocopies and forms generated from ink jet or laser printers cannot be scanned.
Don't: Handwrite information on the document. Handwriting is only accepted for signatures. Handwritten clams require manual processing.
Do: Align the printer correctly so that characters appear exactly in the proper fields. Enter all information within designated fields.
Don't: Allow characters to touch lines.
Don't: Use broken characters (dot matrix), script, slant, minifont, or italicized fonts or expanded, compressed, or bold print. Use fonts that have the same width for each character (proportional).
Do: Keep characters within the boarders of each field. Use 10-pitch Pica or Arial or 10-, 11-, or 12-point type.
Don't: Strike over any errors when correcting or crowd preprinted numbers; OCR equipment does not read corrected characters on top of correction tape or correction fluid.
Do: Complete a new form for additional services if the case has more than six lines of service.
Don't: Use highlighter pens or colored ink on claims.
Don't: Use decimals in Block 21 or dollar signs ($) in the money column.
Don't: Use narrative descriptions of procedures, modifiers, or diagnoses; code numbers are sufficient.
Don't: Use N/A or DNA when information is not applicable. Leave the space blank.
Don't: Use paper clips, cellophane tape, stickers, rubber stamps, or staples.
Do: Enter 6-digit or 8-digit date formats, depending on the block instructions.
Do: Deep signature within signature block.
Don't: fold or spindle forms when mailing.
Do: Enter information via computer keyboard. Use clean equipment and quality ink-jet or laser printers.
Do: Use original claim forms printed in red ink; photocopies and forms generated from ink jet or laser printers cannot be scanned.
Don't: Handwrite information on the document. Handwriting is only accepted for signatures. Handwritten clams require manual processing.
Do: Align the printer correctly so that characters appear exactly in the proper fields. Enter all information within designated fields.
Don't: Allow characters to touch lines.
Don't: Use broken characters (dot matrix), script, slant, minifont, or italicized fonts or expanded, compressed, or bold print. Use fonts that have the same width for each character (proportional).
Do: Keep characters within the boarders of each field. Use 10-pitch Pica or Arial or 10-, 11-, or 12-point type.
Don't: Strike over any errors when correcting or crowd preprinted numbers; OCR equipment does not read corrected characters on top of correction tape or correction fluid.
Do: Complete a new form for additional services if the case has more than six lines of service.
Don't: Use highlighter pens or colored ink on claims.
Don't: Use decimals in Block 21 or dollar signs ($) in the money column.
Don't: Use narrative descriptions of procedures, modifiers, or diagnoses; code numbers are sufficient.
Don't: Use N/A or DNA when information is not applicable. Leave the space blank.
Don't: Use paper clips, cellophane tape, stickers, rubber stamps, or staples.
Do: Enter 6-digit or 8-digit date formats, depending on the block instructions.
Do: Deep signature within signature block.
Don't: fold or spindle forms when mailing.
Do: Enter information via computer keyboard. Use clean equipment and quality ink-jet or laser printers.
Some Hints:
1. ALL WORK ON A CLAIM FORM IS IN CAPITAL
LETTERS.
2. NEVER USE A DASH EXCEPT ON THE ZIP CODE
3. SURGERY SERVICES ARE BILLED AS GLOBAL
SURGERY. THIS WOULD INCLUDE PREOP
VISITS, HOSPITAL VISITS, HOSPITAL DISCHARGE AND POST OP OFFICE VISITS. THE CHARGE FOR THE SURGERY INCLUDES ALL OF
THESE CHARGES.
Block 14: Date of Current Illness, Injury, or Pregnancy (LMP) This block on the CMS-1500 identifies the first date of onset of illness, the actual date of injury, or the last menstrual period (LMP) for pregnancy. A qualifier code is used to determine which date it is. These codes are:
- 431 Onset of Current Symptoms or Illness
- 484 Last Menstrual Period
Internet Resources for The Paper Claim: CMS-1500 (02-12)
- NUCC Home - http://www.nucc.org/
- CMS-1500 instructions - http://www.nucc.org/index.php?option=com_content&view=article&id=197&Itemid=114
- CMS-1500 Claim Form - http://www.nucc.org/index.php?option=com_content&view=article&id=196&Itemid=112
- Provider Taxonomy - http://www.nucc.org/index.php?option=com_content&view=article&id=14&Itemid=125
- Code Lookup - http://www.nucc.org/index.php?option=com_wrapper&view=wrapper&Itemid=126
- Code Sets - http://www.nucc.org/index.php?option=com_content&view=article&id=22&Itemid=117
- NUCC Announcements - http://www.nucc.org/index.php?option=com_content&view=category&layout=blog&id=8&Itemid=105
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) From the Centers for Medicare & Medicaid Services.
The In's and Out's of Incident to Reimbursement Family Practice Management, November/December 2001.
Making Your Balance Sheet Work for You Online article on accounting methods from Family Practice Management, June 2001.
Manager's Electronic Resource Center Includes online resources and links covering many management topics for health services managers, including Financial Management. Produced by Management Sciences for Health with support from the U.S. Agency for International Development.
Professional paper claim form (CMS-1500) Information site from the Centers for Medicare and Medicaid Services.
Transaction and Code Sets Standards Information site from the Centers for Medicare and Medicaid Services - CMS.
Wisconsin Online Resource Center Select "Business", then "Accounting", to view interactive activities on specific accounting topics.
Agencies, Organizations and Associations
DFL Enterprises, Inc. Commercial site for CMS-1500 forms.
Medicare and Medicaid From the Centers for Medicare & Medicaid Services, formerly the Health Care Financing Administration. Includes a site on Coordination of Benefits Part D and Prescription Drug Coverage - General Information.
Tuesday, September 15, 2015
More CPT coding Internet Resources
A site I found to be very useful is the Optum360coding site which is the site of the coding book I have. They have many coding resources on this site.
https://www.optum360coding.com/CodingCentral/
It is important to link ICD codes with CPT codes to establish medical necessity. Here is a link to dummies.com that talks about that and many more frequently faced problems in the coding world.
http://www.dummies.com/how-to/content/how-to-link-cpt-codes-to-icd9-codes-in-medical-bil.html
CPT coding Youtube tutorials.
https://www.youtube.com/watch?v=eWcYDSs_DEQ
http://www.youtube.com/watch?v=9uIPIwaf1dQ&list=PL9CCC48A0ADF75D7C
CPT Tabbing Youtube tutorial which I found helpful to tab your CPT book and save time finding codes. https://www.youtube.com/watch?v=m5NpJEh_Ji4
Other CPT coding Internet Resources are:
AMA Resources
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page
AMA CPT and RVS Codes
https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do?submitbutton=accept
AAPC Resources
https://www.aapc.com/resources/medical-coding/cpt.aspx
CMS.gov Site
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/TransactionCodeSetsStands/CodeSets.html
https://www.optum360coding.com/CodingCentral/
It is important to link ICD codes with CPT codes to establish medical necessity. Here is a link to dummies.com that talks about that and many more frequently faced problems in the coding world.
http://www.dummies.com/how-to/content/how-to-link-cpt-codes-to-icd9-codes-in-medical-bil.html
CPT coding Youtube tutorials.
https://www.youtube.com/watch?v=eWcYDSs_DEQ
http://www.youtube.com/watch?v=9uIPIwaf1dQ&list=PL9CCC48A0ADF75D7C
CPT Tabbing Youtube tutorial which I found helpful to tab your CPT book and save time finding codes. https://www.youtube.com/watch?v=m5NpJEh_Ji4
Other CPT coding Internet Resources are:
AMA Resources
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page
AMA CPT and RVS Codes
https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do?submitbutton=accept
AAPC Resources
https://www.aapc.com/resources/medical-coding/cpt.aspx
CMS.gov Site
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/TransactionCodeSetsStands/CodeSets.html
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