Category Archives: iMAX Medical Billing Insights

The Front Desk: Your Defense Against Claims Denials

Whether or not a claim is paid or denied has a lot to do with what happens before a patient walks through the door. Incomplete or inaccurate information gathered on the front end can set the stage for a denial before a visit even gets started. “It’s critical to have as complete a patient record as possible before a patient presents,” said Ben Colton, senior manager specializing in revenue cycle optimization at ECG Management Consultants in Seattle, Wash. “As the visit gets closer, you should use all lines of defense to verify information right up to the time of the

Provider Payment Mechanisms May Influence Low-Value Care Use

Fee-for-service providers in the Military Health System were more likely to order 11 of 19 low-value care services compared to salaried providers, a new study shows. A new study in Health Affairs found evidence that patients in the Military Health System received potentially low-value care, but the amount of low-value care varied by how the providers were paid. Researchers defined low-value care as overused or inappropriate care. Such care included procedures and treatments that were clinically inappropriate or inappropriate for a certain population (i.e., prescribing antibiotics for viral infections or cardiac stress imaging in low-risk or asymptomatic patients). Low-value care in the analysis also

Physician Assistant Compensation Up 1%, Showing Workforce Growth

The AAPA reports that median base physician assistant compensation rose from $105,000 in 2017 to $106,000 in 2018, outpacing inflation over time. Median base physician assistant compensation increased from $105,000 in 2017 to $106,000 in 2018, representing one percent growth during the period, the American Academy of PAs (AAPA) recently reported. The report, which surveyed 13,088 physician assistants between February and March 2019, also showed the median compensation for physician assistants including base salary, hourly wages, and other forms of productivity pay. In 2018, the median compensation for physician assistants across the entire profession was $107,500. Although compensation varied by specialty

Medical Group Operating Margins Improved in 2018

In terms of medical group operation margins, total profit per physician in independent practices increased, while integrated health systems lost less money per physician. Medical group operating margins for integrated systems and independent practices improved from 2017 to 2018, according to new data from AMGA. The association’s 2019 Medical Group Operations and Finance Survey, which used data from medical groups representing over 15,300 provider FTEs, showed that median total investment per physician in integrated systems improved 21 percent, decreasing from $243,918 in 2017 to $201,042 in 2018. Independent practices also saw a slight improvement in total profit per physician during the

Demand for Medical Specialists Increases, Surpassing Primary Care

Recruiting assignments for medical specialists increased to 78 percent in 2019 as demand for primary care physicians declined, Merritt Hawkins reported. Hospitals, medical groups, and other healthcare organizations increased their demand for medical specialists from 2018 to 2019 despite the industry-wide push for more primary care, according to Merritt Hawkins’ annual report on physician recruiting and incentives. The report, 2019 Review of Physician and Advanced Practitioner Recruiting Incentives, showed that 78 percent of Merritt Hawkins’ recruiting assignments from April 1, 2018, to March 31, 2019 were for medical specialists, including psychiatrists, OB/GYNs, and radiologists. The number of recruiting assignments for medical specialists is

Q/A: What’s the Difference Between Q5 and Q6 for a Substitute Provider?

Question In the situation of a locum tenens/substitute provider, can you help me understand the difference between the Q5 and Q6 modifier and when it would be appropriate to use each one? Answer It’s important to understand that these modifiers are not interchangeable. These modifiers recently had their descriptions changed to clarify some of the problems previously associated with them. Use Q5 when there is a reciprocal billing arrangement and use Q6 when there is a fee-for-time compensation arrangement. Medicare has some specific rules about the time involved so be aware of individual payer policies and their time requirements.

Understanding NCCI Edits

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and policy manual, which identify code pairs considered integral to one another or bundled. An NCCI code pair consists of two codes representing procedures that, when performed during the same operative session, on the same patient, and by the same provider, should not be billed separately because they are considered part of the greater procedure. A different way of explaining this would be to consider how upset you might be if you went to a restaurant and paid for a nice meal but were then asked to pay a separate fee

OIG Announces – New Review For Medicare Part B Payments for Podiatry and Ancillary Services

Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020.  The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.   Part of the OIG’s review and attention will include ancillary services reported in the Podiatrist practice. To better treat patients, improve outcomes and their bottom line, more and more podiatrists are adding ancillary services to their practices.  If you plan on adding ancillary services or are currently reporting these services, be sure you have

Voluntary Repayments

Should you volunteer to repay money from Medicare or other federal healthcare programs if you believe they were the result of errors on your end? The penalties for not doing so could be severe. Under the Federal False Claims Act, if retained overpayments can be shown to be to false claims, they are punishable by up to three times the amount of the false claim, plus between $11,181 and $22,363 per false claim. In 2016, the government published regulations, for Medicare Part-B only, that clarified that retained overpayments must be returned to Medicare within 60 days of the date on

Spotlight: Services Excluded from Global Surgery Payment

The following services are excluded from global surgery payment according to Noridian Medicare.  These services may be paid for separately. The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure; Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;