Our Biggest Sale Ever of Our Online Medical Billing Courses

   We want to give our readers a special “Summer Sale” on our Medical Billing Courses”  All ten of our regularly priced $129.00 courses are now on sale for only $79 each.  Use the coupon code SUMMER for this discount.  Don’t miss this opportunity to learn medical billing or just increase your knowledge in specific areas.

Hurry!  Don’t wait for this extraordinary offer to end.

Here is more information on our available online courses.

If you are interested in a bundle call our office directly at
800-207-4222 X100 for pricing and purchase.

Shop here for ebooks. 
Shop here for online courses.

Here is a list of all our online courses.

  1. Introduction to Health Insurance and the Medical Billing Process
  2. Understanding Coding and Modifiers
  3. Life Cycle of an Insurance Claim
  4. Billing Medicare, TRICARE and Medicaid
  5. Billing Blue Cross/Blue Shield, Commercial, Workers Comp and More
  6. HIPAA, HITECH and Regulatory Issues
  7. Reading EOBs, Handling Denials and Filing Appeals
  8. Working with a Practice Management System
  9. Operating a Medical Billing Business
  10. Marketing a Medical Billing Company


Ignoring MACRA Can Be a Costly Mistake

In April of 2015 President Obama signed the Medicare Access and CHIP Reauthorization Act also known as MACRA into law.     CHIP stands for Children’s Health Insurance Program.    Basically in a nutshell MACRA is going to change Medicare’s traditional fee-for-service method of reimbursement into a value based methodology.    This could have a huge impact on how providers are reimbursed.

MACRA’s implementation will begin in 2019 but it will be based on the reporting year 2017.   The problem is that many in the billing community do not understand what MACRA is or how it will impact their practice.  Even though the implementation is still two and a half years away, the data that will be used to determine a provider’s fee schedule will be based on information reported in 2017 which is only six months away.

Many providers and their staff are totally unaware of the changes that will be implemented.  These changes can greatly affect their cash flow and income.  Ignoring MACRA could be a costly mistake.

So what exactly is MACRA?  Basically the government wants to reimburse providers based on quality of care, not quantity.  Currently providers are reimbursed on a fee for service basis.  They see a Medicare patient and they are reimbursed for that service based on the Medicare fee schedule.  The fee schedule amounts are determined by the SGR formula or Sustainable Growth Rate.  MACRA will replace the SGR formula.   Physicians will no longer be reimbursed based on volume of patients but on value of care.

Experts estimate that there are billions of dollars wasted due to wasteful, redundant and inefficient care.   The SGR formula became too difficult to manage and needed to be replaced.  MACRA will basically allow each provider to have an individual fee schedule based on their performance.  Under MACRA providers will have two options:

Option 1:  MIPS or Merit Based Incentive Payment System.  MIPS combines parts of PQRS (Physician Quality Reporting System), VM (Value based payment modifier) & EHR (Electronic Health Records) incentive program into one program.  Most physicians will be reimbursed based on MIPS.

Option 2:  APM or Alternative Payment Model.  APM provides ways to pay health care providers for the care they give to Medicare beneficiaries by sharing the risk.  Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are examples of APMs.  From 2019-2024 health care providers that qualify for APMs will receive a lump-sum incentive payment.

Most Medicare providers will fall under Option 1 or MIPS.  There are four components of MIPS:

1.    Quality – PQRS (50%)
2.    Advancing Care Information (ACI previously known as EHR/meaningful use) (25%)
3.    Clinical Practice Improvement Activities (CPIA) (15%)
4.    Resource Use (10%)

MIPS defines the financial impact on providers by creating a composite score for each provider.  The composite score will be between 1 and 100 and will be based on the four components above.   This composite score will lead to each provider having their own individual fee schedule.

Composite scores will be posted on a CMS (Centers for Medicare and Medicaid Services) public website know as Physician Compare.  CMS hopes that this will motivate providers by having an effect on their reputation.

Providers who are not reporting PQRS measures receive a 2% penalty for 2016.  Many providers choose to accept this penalty.  Once MACRA is implemented PQRS could have a greater impact on a provider’s reimbursement.  PQRS counts for 50% of a provider’s composite score.

The following is a chart of possible payment adjustments for providers based on their composite score:

•    2019:  +/- 4%
•    2020:  +/- 5%
•    2021:  +/- 7%
•    2022:  +/- 9%

Based on this chart, a provider with a low composite score may receive a payment adjustment of – 9%.  This could have a big impact on a provider’s income.

Currently MU or Meaningful Use is an all or nothing program.  This means that a provider either passes, or meets the requirements for Meaningful Use of EHR, or they fail by not meeting those requirements.   Under MACRA, MU or ACI will no longer be all or nothing.  In the past, a user with 31% was just as compliant as user with 75%.  Under MACRA ACI (previously MU) will account for up to 25% of a provider’s composite score.  The provider will receive credit for the amount of Meaningful Use they demonstrate.

The higher a provider’s composite score, the more they will be reimbursed for services provided to Medicare beneficiaries.  Provider can choose to suffer the penalties but a low composite score will result in low reimbursement for services.  They can also choose to mitigate or reduce the penalties by reporting PQRS and demonstrating meaningful use to increase their composite score.  They can also compete for incentive dollars to improve their fee schedule.

From 2015 to 2019 there will be an automatic 0.5% increase to the current Medicare physician fee schedule.  However this increase can be offset by penalties.   2019 to 2025 the reimbursement will be determined by MIPS or APM depending on what option the provider chooses.

It is urgent that providers prepare now so that their reported information in 2017 will not hurt their income in 2019.  They will have to decide how much time and energy their office will devote to the process.  Software companies are trying to make it easier for providers to reduce penalties by doing back end work to help reporting PQRS and ACI.

Many providers are still not reporting through the PQRS system.  The current penalty does not impact them enough to make a difference.  Many are also not demonstrating meaningful use.  With MACRA PQRS and MU will count for up to 75% of their composite score so it will not be so easy to ignore.

In order to limit the financial impact of MACRA providers will have to report using PQRS, demonstrate MU or ACI, and balance compliance with financial prudence.  It is important to start preparing now.

Two Day Training in Our Office

This week we were privileged to meet and work with two sisters from Massachusetts who started their medical billing business 4 years ago after purchasing our “Medical Billing Business in a Box” book package.  It was so interesting to hear about the progress they have made and to give them ideas and suggestions for further building their business.  It was a very humbling time we spent with them when they told us about their experience as children going to an underground church in Bulgaria.  They knew of a young family who were arrested and imprisoned and sent to hard labor for being Christian.  They were medical students and lost that status.  The worst part was that their father turned them in for not being Communist.  We take so much for granted in this country including the right to go to church.

Brani and her sister came for our two day training and had this to say.

   “The 2 days of training provided by Michele and Alice at their offices of Solutions Medical Billing Inc, were the best investment of time and money we made for our medical billing business.

The training was very intensive and packed with extremely valuable information which empowered us to take our business to the next level.

Before the training, they had prepared a customized agenda, tailored to fit our needs and questions.  From the warm welcoming, to the pleasant environment, to answering all of our questions and providing us with printed materials, Alice and Michele were very professional.

We strongly recommend this training to everyone who intends to start their own medical billing business and get hands-on experience, or to grow their business.  The training far exceeded our expectations.”

Our special 2 day training in our office is designed for anyone starting or wanting to grow their medical billing business.  We work personally with you on any parts of the business you need help with.

Find more information on our two day training here.

MACRA – Medicare’s New Payment Plan

Why does our government have to make everything so difficult?  Seriously the first two articles I read simply identified MACRA as the Medicare Access and CHIP Reauthorization Act of 2015 signed into law on April 16, 2015.  Both articles then went on to say that MACRA was going to be a “potential game changer” of our current health care system.  But neither explained why.

I had to dig around quite a bit before I could really get what I would call any understanding of what MACRA is myself.  So this is my layman’s version of MACRA:

•    MACRA repeals the SGR formula (Sustainable Growth Rate) that used to threaten substantial pay cuts to physicians.
•    MACRA will begin being implemented in 2019
•    There are basically two options for eligible providers.  A.  EPs can participate in MIPS, or Merit-Based Incentive Payment System.  MIPS is a modified fee-for-service model which consolidates PQRS, meaningful use, and value-based modifiers.  B.  If they qualify they can participate in the Alternative Payment Models or APMs.  Participation in APM is entirely voluntary.  APMs are new payment and delivery models approved by CMS.
•    MIPS is supposed to promote better care and smarter spending by evaluating EPs.  Evaluations will be based on quality of care, resourse use, clinical practice improvement activities, and meaningful use of EHR
•    There will be incentive payments for qualifying EPs

I will continue to gather information on MACRA and we will include more articles in the future.  For now there is still time for us to figure out how this will impact providers.  There is also time for them to delay the implementation which seems to be common with all new legislation in the medical field.

Is It Illegal to Waive Co-pays?

Providers often waive co-pays or coinsurance for friends, colleagues and patients who are suffering a financial hardship.   But what is their legal responsibility?  Although you don’t hear of providers being arrested for not charging a patient their share of the cost of the service, the provider can still get in trouble for performing this practice.

First of all there is the issue of offering a professional courtesy.  Professional courtesies must be distinguished from waiving patient responsibilities.  A professional courtesy is when the provider waives the entire fee for a physician, or the dependent of a physician.  A professional courtesy may also be a discount such as 50% for such an individual or the provider may choose to waive only the patient’s out of pocket expenses as well.  This is known as accepting “insurance only” as payment in full.  The issue is that this professional courtesy is often extended to many others such as staff, family of staff, friends, etc.

Generally if the professional courtesy is the waiving of the entire fee or a percentage of the entire fee it is considered legal.  However, if the professional courtesy is waiving the co-pay or the patient responsibility it is generally considered illegal especially if the patient has a federal insurance plan such as Medicare.  This is true even if the patient is a physician.
It would also be considered illegal if the professional courtesy was extended to a patient who is in a position to refer business to the provider.  This could be considered fraud and abuse, especially in the case of Medicare patients.  Waiving patient responsibility for Medicare patients violates a federal statute that states that the provider knows that waiving the patient responsibility is likely to influence the patient to seek care from that provider.

Federal law never allows waivers of patient responsibility to be offered as part of any advertisement or solicitation.  Basically a provider cannot use the enticement of waving the patient’s responsibility to get a patient in the door.  A provider is not allowed to advertise a special where they will waive the patient’s co-pay for a new patient consultation to try to get more patient’s into their practice.

Many providers do not understand why they cannot decide to extend a break for services rendered to a family member or friend.  They feel that they have a right to choose if they want to collect the money that the insurance carrier deems to be the patient’s share.
The insurance carriers feel differently about the situation.  They feel that by waiving the patient responsibility the provider is intentionally charging a different price for the same service.  For example, a provider charges $100 for a level 3 established patient office visit and the patient’s insurance carrier pays $80 and the patient has a $20 copay.  If the provider waives the $20 copay the insurance carrier feels that the provider is willing to accept $80 for the level 3 established patient office visit.  Based on that they feel that they overpaid the provider $20.  They should  have paid $60 and the patient should have paid $20.

Why does the insurance carrier feel this way?  Basically all of these concepts, deductible, co-pay and co-insurance, are cost share obligations.  The rules of managed care state that the patient CANNOT see the doctor until they make their co-payment. Managed care is governed by federal law and is not open to interpretation. To “write-off” a co-pay, or to allow a patient in to see the doctor without collecting the co-payment, is against federal law.

Some individual states agree with the insurance carrier’s perception and have declared the insurance only courtesy is insurance fraud.  If the provider accepts insurance only then the state feels that they are misrepresenting their fees by charging insurance carriers a fee that is higher than the fee that they actually intend to collect.

There are many situations where waiving the patient’s responsibility either in the form of a deductible, co-pay or coinsurance is deemed illegal.  Federal plans and managed care plans are covered under federal law and most commercial plans, depending on the state, are covered under state laws.  If not illegal, it is most likely a violation of the provider’s contract with the insurance carrier.  Violating the contract may result in the provider being removed from the insurance carrier panel.

Basically, providers are not supposed to ‘forgive’ patient responsibilities without proof of financial hardship.  Such financial hardship cases must be consistent and not provided routinely and the hardship should be documented in the patient’s chart.  Therefore, the best course is to avoid waiving the patient responsibility unless a financial hardship has been established.  Office policies should be reviewed regarding any courtesy discounts to make sure that they are compliant.

Making Difficult Decisions

Difficult decisions

There usually comes a time in the medical billing business when we are faced with making a very difficult decision.  This decision may be either that you have to fire an employee or that you have to end a contract with a provider.  In the over twenty years that we have been in business we have had to make a handful of these difficult decisions.

Unfortunately with the number of people that we have employed we have had to make the decision to fire some of them.  With some it was an easy decision.  With others it has been difficult.  The bottom line is if your business is to succeed then you have to make the decision with the best interest of the business in mind.  You can’t go on emotion.

We’ve also had to make decisions throughout the years on ending contracts with some of our providers.  Sometimes those decisions are easy as well.  When we suspect a provider of fraud of any kind we bring it to their attention.  If they are not going to immediately rectify it, we terminate the contract.  No second thoughts.  But sometimes we have to decide to terminate a contract for other reasons.  Reasons that are not as black and white.  It can be a very difficult decision.

But again, we have to think about what is best for the business and sometimes accounts are not good for the business.  This can be difficult to accept, especially if you are just starting out and clients are not easy to come by.  But some accounts can be difficult (not the work itself!) and can actually cost you more to do than you get paid.  Sometimes one account can drain a business and make it so that the other accounts suffer.  It is important to recognize this and consider terminating the contract (or simply not renewing it) if that will be best for your business.

We have seen many businesses faced with difficult decisions.  Many times the owner (including us!) will let emotions come into play.  It is important for the success of your business that you face each decision with the question “What is best for the business?”

Adjustments and Appeals – What’s the Difference?

When does one file an appeal and when is an adjustment to an insurance claim appropriate?  This can be a confusing situation to a new biller.  When a medical insurance claim is rejected or not paid, usually some action must be taken.  Often it is either that an appeal must be filed or an adjustment to the claim made.
The basic difference between an appeal and an adjustment is:
An adjustment is done when a claim needs to be reprocessed for some given reason.  Appeals are done when there is a disagreement with an insurance company’s decision regarding the processing of the claim.
An adjustment is a request that a processed claim be reprocessed based on new or changed information now being provided.  Basically it is a request for information on the original claim to be corrected with this new information.  An example of the appropriate use of an adjustment would be if a claim was submitted with an incorrect diagnosis or CPT code.  The claim may be denied by the carrier and it is discovered that the claim had incorrect information.  An adjustment would then be filed with the correct information.
Some insurance carriers require the use of a specific form which generally may be found on their website to file an adjustment while others may accept a generic one.   Attach a completed adjustment form to the corrected claim and write “Corrected claim” across the top of the CMS 1500 form.   Circle the item that is being corrected and attach a copy of the EOB.
Appeals are filed when one disagrees with the decision the insurance carrier made in processing the claim.  Often claims are appealed for timely filing or when there is additional information that should be considered.  Appeals are sometimes filed by telephone but often either an appeal form or an appeal letter is required.   As with an adjustment, some insurance carriers require the use of their own appeal form which can usually be found on their website.
An example of when an appeal may be needed is if a claim is initially denied stating the service provided was not medically necessary.   However the provider feels that the service was warranted.  An appeal can be filed with a copy of the medical records and an explanation from the provider as to why the service was medically necessary.
For more information on filing adjustments or  appeals with many example letters, check out our ebook “Denials, Appeals & Adjustments”.  From now through Memorial Day you can get a 20% discount on the book with the coupon code SPRING


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