Patient Balances: Are Carriers Calculating the Patient Payment Correctly?

Patient payments are on the rise. You know it and statistics support it. According to AthenaHealth PayerView 2012, the weighted Provider Collection Burden increased by 7 percent from 2010 – 2011 from 16.7 percent to 17.8 percent. Where is it headed in 2013? Higher, of course! Because the patient collection burden is frequently difficult to…

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ICD-10 Implementation: Are You Fit To Be The Champion?

Change always needs a champion. Sometimes we get dragged into change clutching desperately to familiar habits. Other times, a champion emerges to create some enthusiasm and expectation about a new and better way. ICD-10 is the new and better way. According to a number of industry experts, ICD-10 addresses critical gaps and operating flaws inherent…

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ICD-10 and Your Management Care Contract: Hold Harmless or Hold Accountable?

Your ICD-10 preparation checklist seems to be growing, right? Now, stories are beginning to surface that some healthcare organization are being asked to sign off on hold harmless terms related to the upcoming coding overhaul. Healthcare Finance News ran a story this month stating that health entities are negotiating ICD-10 hold-harmless clauses. Victoria Vance, an…

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The 60-Day Appeal Review Standard: Getting Carriers To Answer Appeals

Appeal review deadlines vary from plan to plan and payer to payer. However, there are appeal deadlines applicable to most claims. A 60-day appeal response deadline is common among many types of plans. The Medicare Appeals Process applicable to Fee for Service claims requires that First Level Appeals, Redeterminations, be decided either by a letter,…

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Denial Analysis Often Improves Healthcare Profitability

What gets studied gets improved. This is one of the simplest management concepts yet one of the most challenging when it comes to ambiguous data. What is understood gets improved is the more accurate maxim for analyzing the ambiguous, often uncharted, sea of denial data being generated in the initial stages of healthcare denial management.…

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Using Disclosure Laws to Obtain Usual, Reasonable & Customary Denial Information

UCR denials are often mired in mystery. What does usual, reasonable and customary mean? How are the reimbursement rates calculated? Are payers using governmental entitlement program benefits as a basis for calculating UCR? What proof has the payer collected that actually demonstrates that the denied claim has been billed at a rate above the norm?…

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ERA Transparency & Denials: How Medicaid Remittances May Clog Up The Workflow

Not every medical claim sails through the payer adjudication process. Every healthcare billing professional knows that some claims get dumped right back in your lap for “resubmission.” Here’s the tough question: How many hours does your staff spend on resubmission? And the other critical follow-up question: How much do you collect on resubmitted claims? The…

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Getting The Real Story On A Payer’s Fee Schedule

You have begged and pleaded and finally received the gold mine of information – the payer fee schedule! But, do you have the whole story about how the payer will, or won’t, pay? A complete fee schedule is more than just a list of the Current Procedural Terminology (CPT) codes and the associated contracted rate…

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The Changing of the Code: Quarterly Code Changes May Require Appeal

Are your billing professionals keeping up with NCCI quarterly code changes? Now is the time to review the NCCI quarterly code change report. The NCCI code changes went into effect July 1 and include a number of retroactive code changes that allow you to resubmit claims for additional payment. Further, the NCCI database expanded with…

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Refund/Recoupment: Following The Money

Settlement of a liability claim can take years and insurance carriers have a long memory. Unfortunately, providers get caught in the middle of the money muddle of who should pay and who should refund an overpayment. For this reason, providers need to review overpayment demands carefully. First, know how and if any managed care contract…

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