A Consumer's Guide To The Health Law

Kaiser Health News published a consumer guide to the health law. According to the article, here is what is to come by 2014:

• In 2014, if you don't have health insurance you will have to have it or you will have to pay a fine.
• Individual penalty will be $95/year or 1% of their income (whichever is greater) it will rise to 2.5% (or $695) by 2016
• Family penalty will be $2,085/year or 2.5% of their income whichever is greater.
• Requirement may be able to be waived for reasons for example: financial reasons or religious beliefs
• Federal law will override state laws on blocking requirements to have health insurance.
  
• Insurance at work is likely to stay the same
• Plan may change
• May change premiums, deductibles, co-pays and network coverage.
  
• Some parts of the law that are in place now:
• Eligible for preventative services with no out-of-pocket costs
• Health plans can't cancel your coverage if you get sick
• Children with pre-existing conditions cannot be denied coverage
  
• Government will pay for anyone with an income at or lower than 133% of the poverty level
• $14,856 for an individual and $30,656 for a family of 4
  
• If you don't qualify for Medicaid:
• Subsidies will be available for individuals and families between 133% and 400%
• $14,856-$44,680 for individuals $30,656-$92,200 for families
• 
  
• Information on small businesses providing insurance
• No employer is required to provide health insurance
• In 2014, if your business has more than 50 employees the business will have to pay a fee.
  
• If you're over 65, there are changes listed in the article too.

For the full article, please click the following link: After the Election: A  Consumer's Guide To The Health Law

For additional billing, coding, and reimbursement resources, please click the following link: Medical Reimbursement Resources Page.

Predictive Modeling Analysis of Medicare Claims

Since June 30, 2011, Medicare has implemented a predictive analysis system. The following bullets explains the predictive modeling anaylysis in more detail.

Predictive Modeling Analysis of Medicare Claims

• Predictive Analytics System analyzes Medicare FFS (Fee-for-service) claims in order to detect fraudulent activity.

The modeling technology goes as follows:

• Builds profiles of providers, networks, billing patterns, and beneficiary utilization
• These profiles create risk scores estimating the likelihood of fraud.
• The profiles are automatically prioritized by which has the most alerts and risk score.
• The analysts at CMS then review the cases which were those of high risk score/ high alert.
• Depending on what the analysts find, they take the appropriate action.

What the risk score does to the claims payment:

• Only alert CMS to review the claims activity
• CMS does not deny claims because of predictive model results
• Enables automated cross-checks

To read the full article, please click the following link: Predictive Modeling Analysis of Medicare Claims

For additional billing, coding, and reimbursement resources, please click the following link: Medical Reimbursement Resources Page

Affordable Care Act & Grandfathered Health Plans

Healthreform.gov published an article on Affordable Care Act and "Grandfathered" Health Plans. The purpose of the Affordable Care Act is to give families and businesses more control over their health care

Protecting Patients' Rights in All Plans

• Must provide certain benefits to their customers for plan years starting on or after September 23, 2010.

Additional Consumer Protections Apply to Non-Grandfathered Plans

• They can make routine changes
• Grandfathered plans for policies in effect on March 23, 2010
• Cannot:
• cut or reduce benefits
• raise co-insurances
• significantly raise co-payment charges
• significantly raise deductibles
• significantly lower employee contributions
• add or tighten on annual limit on what insurer pays
• change insurance companies

Projected Impact on Consumers and Plans

• Large Employer Plans
• Small Business Plans
• Individual Health Market
• People in Special Types of Health Plans

Projections of Employer Plans Remaining Grandfathered, 2011-2013

• See chart in article
• Choices in 2014 and subsequent years

For the full article, please click the following link: Keeping the Health Plan You Have: The Affordable Care Act and Grandfathered Health Plans

For additional billing, coding and reimbursement resources, please click the following link: Medical Reimbursement Resources Page

What Employers Should Know About Healthcare Changes Ahead

Insurance Journal published an article on "What Employees Should Know About Healthcare Changes Ahead" The article discussed what would happen after Obamacare.  5% of companies are using the approach in which they give their employees a set amount of money to buy their own health insurance.

The article suggested the follow as to what you can do currently:

• This year's tax season matters
• Look at your tax return you may qualify for subsidies
• Income levels will determine premium costs and what is covered by tax credits
• If you and your spouse file separately consider filing jointly
  
• Educate yourself
• Public Exchanges are going to start October 1, 2013 open-enrollment for health insurance begins.
  
• Save money
• If you have a HSA (Health Savings Account) they are unsure if these will carry-on after 2013 so the article suggested to max these out & you will have money later.
• Insurance costs could rise in 2014

For the full article, please click the following link: What Employers Should Know About Healthcare Changes Ahead

For additional billing, coding, and reimbursement resources please click the following link: Medical Reimbursement Resources Page

Coding Changes for 2013

ACP Internist published an article with updates on coding changes for 2013. In the article they discussed the revised ICD-9 update schedule as follows:

• Oct 1, 2011 - ICD-9 & ICD-10 code sets
• Oct 1, 2012 - limited code updates for ICD-10 (no updates to ICD-9)
• Oct 1, 2014 - limited code updates to ICD-10 code set (no updates to ICD-9 since it no longer will be used)
• Oct 1, 2015 - regular updates to ICD-10 will begin.

New Care Management Codes

• Will be introduced in 2013
• Reporting and reimbursement of non-face-to-face care for complex, chronic illnesses & have been discharged from a hospital or facility not described in CPT or HCPCS codes.

Complex Chronic Care Codes - allows physicians & qualified health professionals to report the work & time they spend on a patient's care (including non-face-to-face elements)

• 99487
• 99488
• 99489

Transitional Care Management Codes - codes for follow-up care after the patient has been discharged from a facility setting.

• CPT 99495
• communication with the patient or caregiver within two business days of discharge
• MDM of at least moderate complexity during the service period
• face-to-face visit within 14 calendar days 
• CPT 99496
• communication with the patient or caregiver within two business days of discharge
• MDM of at least moderate complexity during the service period
• face-to-face visit within 7 calendar days

For the full article, please click the following link: Variety of Coding Changes Loom For 2013.

For additional billing, coding. and reimbursement resources, please click the following link: Medical Reimbursement Resources Page.

2013 Radiology CPT Code Update

An article published by the American College of Radiology discusses the following codes that have changed in 2013. Below is how the article broke down the Radiology Codes by specialty.

Diagnostic Radiology

• Revised - Cervical Spine Codes
• 72040, 72050, 72052
• Deleted - Bronchography
• 71040, 71060

Interventional Radiology 

• New - Thoracentesis & Pleural Drainage Codes 
• 32554, 32555, 32556, 32557
• Deleted - Pneumocentesis & Thoracentesis
• 32420, 32421, 32422
• New - Cerviccocerebral Artery Studies
• 36221, 36222, 36223, 36224, 36225, 36226, 36227, 36228
• Deleted - Cerviocerebral Angiography Codes
• 75650, 75660, 75662, 75665, 75671, 75676, 75680, 75685
• New - Retrieval of Foreign Body
• 37197
• Deleted - Foreign Body Retrieval Codes
• 37203
• New - Thrombolysis Codes
• 37211, 37212, 37214
• Deleted - Thrombolysis Codes
• 37201, 37209, 75900

Nuclear Medicine

• New - Endocrine and Parathyroid
• 78012, 78013, 78014, 78071, 78072
• Revised - Parathyroid Codes
• 78070
• Deleted - Endocrine Codes
• 78000, 78001, 78003, 78006, 78007, 78010, 78011

Radiation Oncology 

• New - Stereotactic Body Radiation Therapy Code
• 32701

Category III Code Changes

• New - Focused Microwave Ablation Code
• 0301T
• Extended - CAD and HDR Brachytheraphy Codes
• 0174T, 0175T, 0182T

For the full article, please click the following link: 2013 CPT Code Update - Radiology.

For additional billing, coding, and reimbursement resources, please click the following link: Medical Reimbursement Resources Page.

More Health-Law Changes Coming in 2013

The Wall Street Journal published an article titled: "More Health-Law Changes Coming in 2013". The article listed the following 5 changes that will come about in the year 2013. They are as follows:

1. Higher Premiums
• 13% of companies planning to raise their employees contributions by 5% or more.
• Insurers give rebates to consumers if the insurers spend less that 80% of premiums on medical care.
• In 2012, 13 million consumers got rebates worth $1.1 billion dollars
  
2. Straightforward Summaries
• Easy-to-read descriptions of how the plan works.
• What it covers and doesn't cover - no fine print.
• New glossary of insurance words that you may not understand
  
3. FSA Limits
• $2,500 is the maximum you can put in a flexible spending account.
• FSA are tax free money that you can use to pay qualified out-of-pocket expenses for 
• Examples: copayments for doctor visits or prescriptions
• If you don't use the full amount that you put aside, you will lose that money.
  
4. Dependent Coverage
• Children up to age 26 can stay on their parents' policies
  
5. Higher Spending Cap
• This year (2013), the spending cap is $2 million
• In 2012, the spending cap was $1.25
• In 2014 the spending cap will go away entirely.

To view the full article, please click the following link: More Health-Law Changes Coming in 2013

For additional billing, coding, and reimbursement resources please click the following link: Medical Reimbursement Resources Page.

Five Ways Your Health Care Will Change in 2013

On December 26, 2012, The Washington Post published an article on "Five Ways Your Health Care Will Change in 2013".  The basis of these gradual changes rolling out in 2013 are a result of the Affordable Care Act and federal subsidies to purchase health insurance.

1. Health-care cost growth will slow to a new low
• US expected to spend $2.9 trillion on health care in 2013 (3.8% more than estimated $2.8 trillion that was spent in 2012.
• If the 3.8% growth rate happens it will be the slowest growth in decades
  
2. Your Medicare taxes will increase
• 7.65% is taken out of wages to support the elderly and disabled.
• 1.45% goes towards Medicare's hospital bills
• Medicare hospital tax increased by 0.9% in 2013
• Creates a new 3.8% tax on investment income
  
3. Your insurance plan will be explained in plain English
• Easy-to-understand terms
• Health plans with open enrollment after September 23, 2012 are this way.
  
4. Primary care providers in Medicaid will get a 73% raise
• Estimated 7 million new enrollees in 2014.
• Expanding Medicaid program to 133% of the poverty line
  
5. The Obamacare exchanges will be open for business.
• October 1, 2013 is the more significant deadline as health care exchanges open that day
• Health care exchanges will allow Americans to go online, compare plans and purchase health insurances

To view the full article, please click the following link: Five Ways Your Health Care Will Change in 2013

For additional billing, coding and reimbursement resources listed by specialty, please click the following link: Medical Reimbursement, Inc. Resources Page.

Coding and Documentation

In need of coding help?

AAPC's Coding Edge Magazine published an article on  documentation and offered the following tips:

• Reports Don't Need to Be Lengthy to Be Complete
• Minimum requirements that need to be in the medical record are the following:
• 1. History of present illness (HPI)
• 2. Examination
• 3. Medical Decision Making (MDM) components
• If you are documenting radiology, you must document the technique as well as the findings of the study
• Documentation Must Be Relevant
• Extraneous documentation can do more harm than good
• Stick to what's relevant and be thorough
• Documentation Must Support Specific Coding
• Select the code that accurately identifies the service or procedure performed
• Documentation my support the code you select
• Document Same-Day Procedure, E/M with Special Care
• Procedures provided on the same day as an E/M service may cause red flags
• When you report an additional study your documentation must pass the "highlighter test" - supports the initial service

• * Important to remember the "golden rule" - "If it isn't documented, it wasn't done"*

To download the full article, please click here: Let Documentation Drive Your Coding

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Long Waits at the Doctor's Office Disrespect Patients

KevinMD.com blog posted an article on "Long Waits at the Doctor's Office Disrespect Patients" in the article they explained various reasons why you are kept waiting and different ideas as to what you could do about your wait issues.

The article stated:

• The average time patients spend waiting in 24 minutes
• The average wait times for specialists are longer than general practitioners.

Possible reasons why you are kept waiting:

• The office overbooks & schedules multiple appointments at the same time
• The doctor could have to go to a different office and be running late
• The doctor could be late

What the practice could do for you:

• Call or email if they are running late
• Give you a paging device (similar to restaurants)
• Inform you about the situation at check-in

What you can do:

• Book the first appointment of the day
• Call ahead and ask how the day is going before your scheduled appointment time
• Ask the office staff how long the wait will be
• Explain your frustration to the office staff/doctor
• Find a new doctor

For the full article, please click the following link: Long Waits at the Doctor's Office Disrespect Patients

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources Page

How High Deductible Plans Lead to Low Healthcare Spending

An article published from Forbes titled “How High Deductible Plans Lead to Low Healthcare Spending” shed some light on the impact that high-deductible health plans are having on consumer's healthcare spending. Highlights from the article are as follows:

• There was a 3.8% increase in health costs in 2009 &  a 3.9% increase in health costs in 2010 this equates to the slowest growth rate in 50 years
• There was a 14% increase from the 2010 total individuals enrolled in consumer-directed health coverage
• Health Savings Accounts (HSA) allow people to save their pre-taxed income to spend it on their health care needs
• A study from RAND Corporation concluded that someone who switches from a traditional health plan to a consumer-directed health plan uses 14% less medical services
• More consumers using directed plans would reduce national health spending
• Also according to the study from the RAND Corporation stated that expanding employers with plans such as 50% would reduce health costs by $57 billion per year.

To download the full article, please click here: How High Deductible Plans Lead To Low Healthcare Spending

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources.

Emergency Room Patients Across Country Paying Upfront For Non-Urgent Care

More and more individuals are going to the emergency room.  Some of these visits may be from people who do not truly have an emergency.  Citizensvoice.com published an article titled: "Emergency Room Patients Across Country Paying Upfront For Non-Urgent Care" some key takeaways from the article included:

• The number of emergency room visits has risen by 11% in he past five years.
• The number of emergency departments (based from article for the state of Pennsylvania) has shrunk by 10%.
• An estimated 8% of emergency room visits across the country are for problems that could be handled at a walk-in clinic or primary care facility (statistic based on the U.S. Centers for Disease Control & Prevention).
• A growing number of visits to the emergency room are from problems such as sprained ankles, coughs & colds.
• The EMTALA (The Emergency Medical Treatment and Active Labor Act) passed in 1986 states that hospitals are required to administer medical screening examination to any patient to comes to the emergency room.
• Many hospitals collect a fee or co-pay for services provided for non-emergency care in the emergency room.
• Some hospitals may even have an on-site urgent care clinic that they can send the emergency room patients who do not need care in the emergency room - upon doing this they can free up space in the emergency room and treat sicker patients faster.

For the  full article, please click the following link: Emergency Room Patients Across Country Paying Upfront For Non-Urgent Care

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Emergency Rooms vs. Urgent Care: Differences in Services and Costs

Debt.org published an article on the differences in services and cost on Emergency Rooms and Urgent Cares. Highlights of the article are located in the bullets below:

Emergency Rooms

• Have 5 Levels of Care
• Level 1 is Minor Problems and Level 5: More Severe Problems
• Required to provide care to all patients
• $18 billion could be saved if patients with non-urgent medical problems go to a primary or preventive care center.

Emergency Room Costs

• ER Costs correspond with the severity of the patients illness or injury
• Physician's Fees are typically about 20-25% of the total charges
• Costs vary in different parts of the country
• Average visits in 2009 were $1,318
• Average in-network visit in 2011 was $933
• Average visit in 2009 for common illnesses - (middle ear infection, pharyngitis and UTI) was $570 

Urgent Care Centers

• Free-standing, walk-in medical facilities that provide care with no-appointments.
• They are open extended hours as well as nights and weekends.
• Serve those with non-life threatening medical situations.
• Take in $13 billion dollars in revenue annually.

Urgent Care Center Costs

• Less significant costs than the Emergency Room
• Urgent care estimates say that the visit can cost anywhere from $71 to $125

Paying For Emergency Room Visits

• Private insurance: 54%
• Medicare: 38%
• Medicaid: 33%
• Uninsured Patients: 35%

Paying For Urgent Care Visits

• Fee-for-service basis
• Usually accept most private insurance plans
• Co-pays are around $25-$50 per visit for those who have health insurance
• Discounts are usually offered for those without insurance.

For the full article, please click the following link: Emergency Rooms vs. Urgent Care: Differences in Services and Costs.

For additional billing and coding resources  please click the following link: Medical Reimbursement Billing and Coding Resources Page.

Patient Perceptions on No-Shows

According to a study published by Annals of Family Medicine, there are many reasons why people do not show up to their scheduled appointments. The study stated on average that 42% of appointments were no shows. The study then went on to state the following as potential reasons why the patient didn't show:

• Trouble getting off work
• No child care
• Lack of transportation
• Too costly
• Patients who scheduled their appointments in advance and then felt better also failed to show up to their appointment.  
• Patients also felt "too unwell" to show up to their appointments
• Some people felt "emotional barriers" and the negative emotions that go along with going to the doctor and feel that people could go to the doctor for one thing and then they could have other underlying issues that the doctor may find.

For the full article, please click here: Why We Don't Come: Patient Perceptions on No-Shows

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Co-Pay Collection Best Practices

TransforMED published an article on co-pay collection best practices. Some key points from the article are as follows below:

• Establish Co-Pay Collection Policies and Procedures

• The article suggests that the best time to collect co-pays is when the patient is in your office.
• Once the patient leaves the office it is more difficult (and expensive) to collect their payment
• Develop a policy that states that co-pays will be required before the patient's appointment

• Who Collects?

• Determine an individual who is responsible for collecting the co-payments - usually this is the front office staff at the reception desk.
• Ensure that your collection process is monitored

• A Team Effort

• Make sure to confirm the patients insurance and co-payments when they schedule their appointment.
• The patient should also be reminded that they will need to bring their insurance card as well as their co-pay when they come for their visit.
  
• "How will you be paying today?" Some ideas for collecting co-payments are below:
• Use a credit/debit card machine (although this will come with a cost of usually 2-3% for the transaction cost and around $.25 per transaction)
• Install ATMs in the lobby

• Train and Reward Your Staff

• Use lines such as: "How will you be paying for your services today, cash, check or credit?" by saying this you are giving them more than one option to pay.
• If the patient knows they need to make the co-payment ahead of time, they should not be shocked when you ask for the payment.

• Communicate with Patients: if this is a new policy for you, you need to be sure to communicate with the patient about this. The following are a few of the ways introduced in the article:

• Place signs in your office
• Mail out letters introducing the new policy to your patients
• Have the patients sign a form at check-in with an overview of your new policies and procedures on collecting co-payments.

For the full article, please click the following link: Co-Pay Collection Best Practices

For additional billing and coding resources, please click here: Medical Reimbursement Coding and Billing Resources.

Health Care Exchanges Under the Affordable Care Act

The New York Daily News published an article on the future of health insurance and what you can expect from health care exchanges.  These changes will start in fall of 2013. Some key takeaways from the article are listed in the bullets below:

• The goal is quality coverage for millions of Americans who do not have health insurance.
• Individuals and Families will have a choice of private health plans 
• The government will help many middle class households pay their premiums
• Open enrollment will start on October 1st, 2013. Enrollment will be online, storefront operations as well as help at call centers.
• Coverage will take place on January 1, 2014 and everyone will be required by law to have health insurance.
• There will be penalties for some individuals:
• For example, as cited in the article: smokers will face a financial penalty and younger "well-to-do" people may not be eligible for income-based assistance.
• There is some concern that the people who need (and will benefit) from the help the most are unaware that these changes are coming and won't benefit when it is first available.

For the full article, please click the following link: The Future of Health Insurance: What to Expect From Health Care Exchanges Under the Affordable Care Act

For additional billing and coding resources, please click here: Medical Reimbursement Billing and Coding Resources.

High-Deductible Health Plans

Rand Corporation completed an assessment on high-deductible health plans and 800,000 families were studied across the United States. Some key highlights of the study were as follows:

• Spending dropped 14% when they had a higher deductible
• Spending was lower when the individual had a high-deductible plan.
• When the individual had employer contributions contributing to more than half their deductible, savings decreased.
•  Costs went down dramatically the first year people had a high-deductible plan 
• High-deductible and consumer-directed plans help control health care costs
• Patients in the study also reduced their preventive care visits (to reduce their spending) but down the road this could be costly as they could have worsening health problems
• Under the Federal Patient Protection Affordable Care Act (ACA) health plan deductibles must be waived when there is preventative treatments. 
• In the short run high-deductible plans are working but they discourage people from getting preventative care.  

To read the full article, please click the following link: High-Deductible Health Plans Finds Substantial Cost Savings, but Less Preventative Care

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources