Physician Credentialing: Worth Getting Right to Get Paid

As physicians, despite your reputation for benchmarked medical services, you could be losing out when it comes to realizing medical bills reimbursed fully from respective health insurance carriers. And when you start to analyze that elusive reason responsible for hampering your reimbursements, you would invariably end up discovering ‘Credentialing’ as the chief culprit. Quite contrast to the earlier scenario, wherein your credential as a qualified and competent practitioner could alone determine your practice’s sustenance and growth, the present day scenario, characterized by innumerous practitioners and heterogeneous mix of insurance carriers, requires your practices to bear the stamp of ‘Credentialing’ to stay well clear of audit, delay or denial exposures.

Although, physician practices require to be credentialed from Federal Health Agencies (for being compliant with requisite health care standards) as well as Medicare and Medicaid, and respective private insurance carriers (for being compliant with medical billing standards), it is the latter that assumes greater significance as it has direct impact on operational optimization and revenue maximization. Credentialing in the medical billing context means that your medical practices are compliant with the benchmarked clinical and operational practices as deemed suitable by the prevailing health insurance convention. And as we stand at an important juncture when health insurance sector is realigning its revenue structure post the Federal Government’s radical healthcare reforms, there is a growing emphasis being laid on Credentialing, first by the Centre for Medical Services, and then by private insurance carriers – making it mandatory for physicians to have their practices duly Credentialed.

But, owing to its exhaustive process, Credentialing itself could be one of your major pre-occupation, relegating the all important medical practice to the second! Here are the series of process that would invariably have to clear for being eligible to Credentialing:

•  Preparation of paper CMS 855 & other Managed Care applications for all payers
•  Preparation and submission of online applications to federal and non-government carriers
•  New provider affiliations and Group Contracts
•  Maintaining and updating specific Provider information directly with carriers at frequent intervals or when requested
•  Resolving enrollment issues and tracking Managed Care contracts
•  Validating information provided by payers
•  Handling Provider letter of interest & enrollment transactions
•  Setting of Provider information in the Practice System
•  Obtaining Contracted Fee Schedules and negotiating changes
•  Preparation of contracting documents for scanning and long-term storage electronically
•  Preparing, maintaining and monitoring Managed Care Summaries that Provides Effective dates, Fee Schedule details and Group affiliation.
•  Monitoring Expiry dates for NYS-Registrations, DEAs, and CLIA registrations and also handling re-applications for the same.
•   Handling Re-Credentialing whenever required
• But, because of its inevitability and the incidental benefits that come with a well-documented Credentialing, it is prudent that you outsource from competent and proven medical billing companies that can offer quality services at a more economical cost than it would cost if it done internally. The following overriding advantages should amply justify the efficacy of going for outsourced Credentialing:
•  Insurance carriers pay better to the physicians who are in par with the insurance
•  Credentialed physicians are considered as reliable providers and are listed in the ‘preferred physicians group’ from which patients usually select their physicians in order to get maximum benefits and avoid ‘out of the pocket expenses’.
•  Since physician credentialing involves complete background check on providers’ educational qualifications, professional licenses, experience, fellowship programs, and residence, it helps in controlling the healthcare fraud-related crimes and ensures that only qualified physicians deliver services to patients and thereby improving the quality of healthcare in US
•  Credentialing offers comprehensive access to the fee schedule, which aids in knowing in advance the exact quantum of medical billing for diverse medical practices rendered.
•  Credentialing is also an accelerator of strategic clinical networks and market expansion as your practices begin to command unprecedented goodwill in the medical fraternity.

We, www.medicalbillersandcoders.com – known for offering imperial Credentialing, both as an individual component as well as an integral part of our comprehensive suite for Medical Billing Revenue Cycle Management – should be your preferential choice for “Outsourced Credentialing”.

Paid-sick-days concept as a preventive option for Federal healthcare expenditure

“Coming at a time when Federal Government itself is promulgating radical healthcare reforms to tackle growing medical expenditure on public healthcare, and promote efficient and quality medical care to its ever growing insured population, this paid-sick-days concept promises to complement the macro healthcare reforms formulated by the Federal Health Department.”

 

Strange it might seem, yet there seems to be substance in the thinking that offering employees with paid-sick-days option will eventually bring down Federal healthcare spending on emergency medical services. The logic sources its root to a forthcoming report by the Institute for Women’s Policy Research (IWPR), which estimates that giving employees access to paid sick days would reduce visits to hospital emergency departments (ED) and save $1 billion in medical costs annually; currently public insurance programs support approximately half this bill.

Although the projected saving is roughly around 2% of the total spend of approximately $47 billion annually on emergency department services, there is growing consensus among the policy makers the paid-sick-days option would encourage a proactive and preventive healthcare conscience amongst the employees and their dependents, who otherwise would procrastinate medical visits for seemingly trivial cases that potentially would be more serious. Thus, by encouraging a proactive and preventive healthcare conscience, Federal Healthcare Body can look forward to ensuring a healthy population as well as substantial cumulative savings on public insurance programs such as Medicare, Medicaid, Medicare, Medicaid, SCHIP, and Veteran Affairs Services.

Coming at a time when Federal Government itself is promulgating radical healthcare reforms to tackle growing medical expenditure on public healthcare, and promote efficient and quality medical care to its ever growing insured population, this paid-sick-days concept promises to complement the macro healthcare reforms formulated by the Federal Health Department.

Quite presumably, there would be an additional burden on physicians committed to serve Medicare, Medicaid, SCHIP, and Veteran Affairs Services beneficiaries, who would show propensity to regular medical visits, encouraged by the paid-sick-days concept. Although physicians can count on pay-for-service fees, the potential growing volume would surely put their practices under tight schedule that would render them vulnerable to operational and administrative in-efficiencies. As their practices’ fortunes hinges solely hinges on efficient clinical management and operational management practices, a dedicated clinical management and operational management service becomes crucial. With in-house services failing to match up to the requisite bench-mark, outsourcing seems to be a viable option.

And, when you contemplate on hiring such competent outsourced services, Medicalbillersandbillers.com name should invariably crop up owing to its credible history in being an able ally to a diverse composition of clients comprising Cardiology, Dermatology, ENT, Endocrinology, Family Med, Gastroenterology, Internal Medicine Sub-Specialty, Internal Med,

Long-Term Care, Neurology, Neurosurgery, OB/Gynecology, Occupational Medicine, Orthopedics, Physiotherapy, Pediatrics, Podiatry, Psychiatry, Pulmonology, Rheumatology, Sleep Med, Surgery, Urgent Care, Urology, and the rest.

Therefore, if you are looking at cost-effective yet efficient medical billing and practice management services, Medicalbillersandcoders.com ingenious and comprehensive Revenue Cycle Management – comprising Patient Enrollment, Insurance Enrollment, Scheduling, Insurance Verification, Insurance Authorizations, Charge Entry, Coding, Billing and Reconciling of Accounts, Denial Management & Appeals and Physician Credentialing – should be an ideal choice.

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Radiology: Finding New Meaning in “Meaningful Use”

Radiologists in the United States are currently facing a dilemma as far as “meaningful use” (MU) of Electronic Health Records (EHRs) is concerned. The American College of Radiology (ACR) IT and Informatics Committee leaders and staff have met the National Coordinator for HIT (ONC) as well as Center for Medicare and Medicaid Services (CMS) staff to discuss the HR incentive program from the point of view of radiologists, on October 13, 2011.

The American College of Radiology committee reiterated its previous requests for certain criteria regarding meaningful use such as – the sharing or accessing imaging data as part of Meaningful Use, robust radiology order entry requirements for referring physicians with appropriate clinical decision support, and addressing Meaningful Use challenges within the radiology community and other specialties.

The American College of Radiology Meaningful Use Report

A report released by the ACR regarding Meaningful Use for radiologists specifies the steps taken by the CMS regarding some of the “Core” and “Menu” objectives and their relevance to radiology. The reports summary states that according to the Continuing Extension Act, outpatient hospital settings (POS Code22) are not considered hospitals in the EHR incentive program. A vast majority of radiologists will be eligible for the Medicare version of the EHR incentive program.

Defining Hospital-based Physicians

The report by ACR also states who would be considered as hospital-based by the CMS and would be ineligible for the incentive program. The CMS defines hospital-based physicians as those providing 90 percent or more of their covered professional services in inpatient (POS Code 21) and emergency room (POS Code 23) settings. Therefore hospital-based radiologists who do not meet the above mentioned criteria are eligible for the Medicare incentive program. However, Medicaid eligibility has stricter rules that require the EP’s 30 percent volume must be attributable to Medicaid which is a tall order for any radiologist if not impossible.

Who is Qualified?

The Medicare version of the incentive program only applies to physicians and radiologic technologists, medical physicists, or other technical staff is not eligible. However, the Medicaid version of the incentive program is limited to physicians, Certified Nurse Midwives, Nurse Practitioners, and Physician Assistants who furnish services in a Federally Qualified Health Center or Rural Health Clinic that is led by a Physician Assistant.

Radiologists vs. Primary Care

The meaningful use objectives appear to be focused on primary care and present some confusion as to how radiologists would comply with such objectives. However, CMS provides exclusions to many meaningful use measures as well as “menu set” measures to counteract this problem to adjust specialties such as radiology.

RIS and PACS

According to the report by ACR many HIT products that are not considered traditional, complete EHR/EMR could still achieve certification via the EHR module pathway. However, these modules need to be tested and certified before they are considered certified EHR technology. Moreover, there are advanced RIS solutions that have already received complete EHR certification or are in the process of receiving it. This implies that RIS/ PACS can be adopted so as to be certified EHR technology in the near future.

The Exclusions for Radiology in Core and Menu Objectives

Out of the 15 core objectives there are nine that are not excluded and are – Drug-Drug and Drug-Allergy interaction checks, update problem list, medication list, medication allergy list, record demographics, report clinical quality measures to CMS, implement CDS rule, HIE test, and security risk analysis. For all other core objectives, exclusion is available for radiologists. As far as the “menu” objectives or discretionary objectives are concerned, only two out of the ten objectives are given exclusion for radiologists. These two menu objectives exclusions are – generate list of patients by specific conditions and patient-specific education resources. All the other eight objectives are not excluded for radiologists.

The anxieties over radiologists’ eligibility for the incentive program are now slowly being dissolved due to the correction and amendments made by ONC. The vast majority of radiologists are eligible for incentives; even those that are hospital based, if they meet certain criteria laid out by the ONC.

For more information about “meaningful use”, EHR certification and implementation, PMS implementation, consultancy, and medical billing and coding services, please visit medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States.

Tackling the Demands Of Gastroenterology Medical Billing in Illinois

Like most of the states in the US, Illinois too boasts of quality medical services. Lying in the Midwest region, Illinois population, being the largest in the region at 12,830,632 as per 2010 census, offers endless opportunities for diverse medical practitioners. Coupled with the demands of the ever-increasing population, Illinois’ robust economy, estimated to be US$652 billion, and per capita income at US$41,411, has greatly been influential in encouraging medical infrastructure for diverse medical disciplines. Whereas Illinois commands as great goodwill as the rest of states in attracting practitioners and patients alike, it has its edge in being a major destination for Gastroenterology Medical Services that merits a special mention: “of the 44 U.S. News Best Hospitals in the Chicago, Illinois metropolitan area, 19 are nationally ranked or high-performing in Gastroenterology, the care of digestive-tract disorders” – as per the survey conducted by a medical agency.

While the survey findings speaks highly of Illinois’ progress to being a front-runner in Gastroenterology, strangely there has been  a shortage of gastroenterologists in the wake of disproportionate population growth, and alarming rise in digestive-tract disorders warranted by life-style changes. Path breaking advances in diagnostic and treatment procedures have been catalyst to rapid expansion of scope of Gastroenterology. The scenario has prompted an unprecedented increase in workload for the existing Gastroenterologist, who, considering the critically sensitive nature of their practice, have rarely been able to take their eyes off their core concern of quality medical care to their patient fraternity; leave alone time and resources for medical billing management.

Having to take on mounting loads of practice, Gastroenterologist have been losing on efficient management of medical billing management, which is the fulcrum on which their sustenance and growth hinges on. But, inevitably, before it becomes detrimental to their very existence as Gastroenterologists, they need to seek out ways to balance their progressive medical care with efficient medical billing management. With in-house gastroenterology medical billing being largely unsuccessful both cost and result-wise, an outsourced gastroenterology medical billing solution has seen a better results.

Yet, physicians/hospitals need to be weary of unscrupulous service vendors so as to avoid repenting on wrongful choice of outsourced gastroenterology medical billing solution. A thorough examination for the prospective vendor’s self-sufficiency in the requisite qualification and competence – certification from  American Association of Professional Coders (AAPC); expertise in advanced technology interface for medical billing and coding;  proficiency in applying standard CPT, HCPCS procedure and supply codes, and ICD diagnosis coding as per CMS guidelines and HIPAA compliant medical reporting – should be the yard-stick to judge its credentials as a medical billing solution provider.

About Medicalbillersandcoders.com

Medicalbillersandcoders.com – known for their credible medical billing to diverse disciplines in gastroenterology through accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards – have been able to turnaround many a gastroenterology practices with simplification of revenue cycle, appreciable increase in collection rates, more patient inflow and referrals, and Increased avenue for medical research and development.

Effective patient care versus revenue cycle management: physicians perform a balancing act

Physicians in the U.S., despite ranking high for their medical competence, have never been able to fully realize and optimize their medical bill reimbursements owing to an increasingly complex health insurance system that has been constantly evolving, and characterized by:

• HIPAA Compliant Medical Reporting
• Stringent Billing and Coding Regimen
• Technological Interface for Electronic Billing and Coding
• Multiple-payer Health Care System, both Private Insurance Plans, and Federal Health Plans such as Medicare and Medicaid.
  • Patient Enrollment
  • Scheduling
  • Insurance Verification
  • Insurance Authorizations
  • Scheduling and Re-scheduling
  • Coding
  • Billing and Reconciling of Accounts
  • Collections
  • AR Collections
  • Denial Management & Appeals
Physicians, whose core concern being the elevation of medical care in congruence with the ever evolving global competitive benchmark, have reported medical billing managementto be an undesirable diversion that can negatively impact their medical efficiency. Experimentation with in-house medical billing practice has not been encouraging either – with in-house staff reporting it to be detrimental to their core function of supportive medical care, or underperforming despite heavy investment on training and system-implementation. Consequently, physicians – with no avail but to practice medical billing somehow – have inevitably been driven to seek professional help in medical billing from medical billing specialists.
Experience has shown that successful medical billing has followed the dictum of perpetual reinvention in tune with stringent compliant standard (coding compliance), privacy compliance regimen (as per HIPAA), and ever advancing technological platforms for billing management cycle – all of which have contributed to an imposing environment that demands a highly qualified, experienced and dynamic team of medical billers, who along with a comprehensive knowledge of billing, are adept at conducting medical billing management in a sequential manner:
Consequently, physicians’ search for comprehensive medical billing service has led them to leading medical billing specialists, such as Medicalbillersandcoders.com – the largest consortium of medical billing professionals, who are adept at accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards.
Carrying impeccable qualifications – certified by the American Association of Professional Coders (AAPC); proficient in using advanced medical billing software such as Lytec, Medic, Misys, Medisoft, NextGen, IDX, etc., and latest coding softwares such as EncoderPro, FLashcode and CodeLink, these medical billing specialist help physicians to streamline their current operations.
Expert at applying standard CPT, HCPCS procedure and supply codes, and ICD-9-CM diagnosis; HIPAA compliant medical reporting; and an impressive track-record of maximizing reimbursement of medical bills with the leading private insurance carriers such as United health , Wellpoint, Aetna, Humana, HCSC, Blue Cross Group, and Government sponsored Medicare and Medicaid as well – our medical billing experts ensure simplification of your revenue cycle, appreciable increase in collection rates and operational margins, more patient inflow and referrals, and Increased avenue for medical research and development.

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The Top 5 States for Physicians to Practice Medicine

The best states in the US for practicing medicine can be determined by taking a holistic view of the state of health care in that particular area and comparing it with other places. Some states are surprisingly physician friendly while some may not be very suitable for physicians in certain specialties. The ranking can be based on factors such as the availability of physicians, disciplinary actions against physicians, the premiums paid for medical liability coverage, cost of living index and state income taxes among many other factors linked to the cost of administration.

Texas

Texas is one of the better states for general surgeons and internal medicine because of the low liability insurance premiums for these specialties. A low cost of living index and low state income tax rates make it one of the top states for physicians to practice medicine. The high percentage of uninsured in this largest state would create a need for health care providers in the future which could be much larger compared to any other state in the country. Moreover, there is no shortage of medical billers and coders in Texas and this makes administrative processes frugal and efficient at the same time.

California

California is the best state as far as physicians’ salary is concerned and is also favorable in terms of Geographic Practice Cost Indices or GPCI. Another feature that is in favor of physicians in this golden state is the comparative lack of competition in the state in many areas coupled with low medical liability premiums.

Alabama

Alabama is one the states where competition is thin for physicians and almost 20% of the people in the age group 19-64 are without health insurance. In face of health reforms, these would be entitled to insurance and the number of patient-doctor encounters would also increase. The cost of living index is lower in Alabama compared to many other states in the US. Furthermore, less number of disciplinary actions by the medical board in Alabama in comparison to other states makes it a place which is lucrative and suitable for physicians.

South Dakota

South Dakota is also one of the states which are ideal for physicians and health care providers due to zero state income taxes and zero liability insurance premiums. Moreover, South Dakota also has a low cost of living index and a comparative scarcity of physicians, making it financially beneficial to provide health care services here. South Dakota is one of the states with very high density of medical billers and coders making it apt for physicians and health care providers from the point of view of administrative and medical billing and coding support.

Tennessee

Tennessee is one the states that is physician friendly mostly because of zero state income taxes, higher pay scale compared to numerous other states, low number of disciplinary actions, and a low cost of living index.  Moreover the easy availability of medical billers and coders in Tennessee makes it ideal for cutting costs as far as the administrative processes related to practicing medicine are concerned.

Although many other states also have positives for physicians but these five states are among the best because all or most of the factors such as cost of living, remuneration, liability insurance premiums, number of disciplinary actions against physicians, state income taxes, GPCI, and number of health providers in the state are in favor of health care providers.

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About Medicalbillersandcoders.com
Medicalbillersandcoders.com is the largest ‘Consortium of Medical Billers and Coders,’ across the US. The portal brings together hundreds of billers, with experience in different specialties, on the same platform to service physicians in their local areas. This network of coders and billers is growing rapidly and is currently servicing over 50 specialty physicians, across the US (Iowa Medical Billing, New York Medical Billing, Ohio Medical Billing, Texas Medical Billing), with the most prominent being Cardiology Medical Billing, Mental Health Medical Billing, Dental Billing, Oncology Medical Billing, and General Practice.

Upgrading to HIPAA Version 5010

Adhering to the HIPAA 4010 compliance has been a long-standing ordeal for medical billing and coding professionals and now, on January 1, 2012, the electronic healthcare transactions standards change from version 4010/4010A to version 5010 will definitely need a closer look at the compliance guidelines. The healthcare industry and professionals need to thoroughly acquaint themselves with the upgraded HIPAA version in terms of its impact and implementation process to provide hassle free medical care.


What is HIPAA Version-5010?


Version 5010 is the latest revised set of HIPAA transaction standards which will be adopted to replace the current version 4010/4010A standards from January 1, 2012. The 4010-compliant “electronic transactions” will not be accepted after this date as being non-compliant with the latest regulation. The electronic health care transactions include functions such as claims submission and status, eligibility inquiries, remittance advices, and referral authorization among others. Unlike the current version 4010/4010A1, version 5010 accommodates the ICD-10 codes, and the application of HIPAA 5010 must be in place first before the changeover to ICD-10.


Impact of Version-5010


It is inevitable that Version 5010 change will have an enterprise-wide effect on physician practices and hospital operations. From front end to back end, the level of impact on a physician’s practice is directly related to how well each practice is prepared to send and receive the 5010 transactions. Physicians practice will have to rely on medical billers and coders who are updated and well trained with the requirements of version 5010.


The updated version of the transactions includes changes in the kind of the data collected as well as the format in which it is reported. For example


1. In the 4010A1 version of the professional claim transaction, anesthesia services may be reported in actual minutes or in units of time. In the 5010 version, only actual minutes may be reported.
2. Another example of a difference in the professional claim transaction is the reporting of the billing provider address. In the 5010 version, the address can no longer be a PO Box or lockbox address.
3. The number of diagnoses that may be submitted increases to 12 from the current 4.
4. The new format will also promote assignment of a claim number upon receipt by a payer. By receiving this claim number in your report of accepted claims, you will have the payers I.D. for that claim to use in following up on unpaid or underpaid claims.
5. Manifold expansion in the size of diagnosis code field.
These changes are likely to improve the billing process and, as a consequence, the patient care. Improvements in the 5010 transactions include
• Clearer instructions
• Reduced ambiguity among common data elements used in different transactions
• Elimination of redundant and unnecessary data elements


So, in order to implement version 5010, the health service providers and organizations need to run an internal assessment, go in for software upgrades and train the various departments. Hiring experts to manage and support the billing and coding processes and software upgrades for implementing version 5010 can take away some of the load during the changeover process.


The following flow chart shows a checklist for version 5010 transitions which you can do in the coming six months.





Understanding these changes and how they will affect medical practices will prepare you for a smoother transition to the updated transactions.


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Upgrading to HIPAA Version 5010