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December 2013 Client Newsletter




December 1, 2013


As you know, insurers are becoming more and more aggressive in trying to find reasons to deny claims.  Horizon has been doing audits for several years.  On November 5th, AmeriGroup announced they are “enhancing” their “code-editing technology to better enforce existing payment guidelines.”  According to AmeriGroup:

What is the impact of this change?
Claims will be reviewed to:
•   Reinforce compliance with standard code edits and rules
•   Ensure correct coding and billing practices are being followed
•   Determine the appropriate relationship between thousands of medical, surgical, radiology, laboratory, pathology and anesthesia codes
•   Ensure compliance with industry standards

What are the sources for these polices? Correct coding guidelines are established by:
•  The Centers for Medicare and Medicaid Services (CMS)
•  The American Medical Association (AMA) CPT® Coding Guidelines
•  National and Local Coverage Determinations (NCD/LCDs)
•  National specialty and academy guidelines”

As we have mentioned numerous times in the past, when an insurer asks for copies of documentation to perform their audit, be sure to review the requested documentation BEFORE sending it.  Does it properly justify all of the services billed, including the E&M code level?  Be sure to send copies of all office notes & reports billed for – including echos, EKGs, surgical procedures, etc.  Have all notes & reports been properly signed (if handwritten, the signature must be legible or typed/stamped below it)?

DO NOT take this lightly as the insurer has a reason for this audit.  We also strongly recommend responding to their request well before the deadline – missing their deadline will very likely result in a “take-back” of all payments.  Failure to respond can also result in being placed on an insurers on “Prepayment Review” – meaning no payment until you send documentation and it is reviewed – which often results in a 45-60 delay in payment.  CPB can help guide you thru this process. 

Reminder when billing Well Visits with other office visit codes (99201-99215) you need to ensure your documentation is either:

• A completely separate note for the Well Visit and the “sick” visit covering the required components for each, or
• Within a single note, a clearly separate section for the Well Visit and the “sick” visit covering the required components for each.


Can we bill any services during the 30-day post discharge period?   Yes. Second and subsequent E/M services after the initial bundled E/M service may be reported. Other diagnostic or therapeutic services may be billed.


Looking at the current billing environment, in 2013 over 33% of healthcare plans (per Kaiser Foundation)  now have high deductible plans. Obamacare will increase this.  This means that without a clear and firm financial policy your cash flow will suffer significantly.  Unless an insurer’s contract with you prohibits it, we strongly urge you to consider a requirement to collect a certain amount of payment for all patients with high deductible plans on the date they are seen in the office.  This ensures at least partial payment to help pay office expenses with additional patient statements for the balance after the insurance processes the claim.  Patients should not expect you to be their de facto “lending institution!”

For those already accepting credit card payments, you have the option of going with more sophisticated programs that offer additional payment options for your patients including automated payment plans.  The costs are about the same as you pay now but with additional options.  

For those using our Scheduler, you can use the eligibility function to find the real time status of a patient’s deductible within less than 20 seconds – at no cost to the practice (CPB pays).  It can be utilized in either batch mode 1-2 days in advance of the appointment, or individually for each patient. 

For those using an EHR, that program should be offering this service.  For those not using our Scheduler, we will usually provide it at no cost to your office (call Rich to discuss). 


We are occasionally asked why providers may not “routinely” forgive patient balances after insurance pays.  Providers that routinely waive Medicare cost-sharing amounts for reasons unrelated to individualized, good faith assessments of financial hardship may be held liable under the anti-kickback statute.  See, e.g., Special Fraud Alert, 59 Fed. Reg. 65372, 65374 (Dec. 19, 1994). Such waivers may constitute prohibited remuneration to induce referrals under the anti-kickback statute, as well as a violation of the civil monetary penalty prohibition against inducements to beneficiaries, section 1128A(a)(5) of the Act.  All states have their own similar prohibitions for non-Medicare patients. 


Medicare’s Part B deductible goes to $147 in 2014.

2013 Client Newsletter Archive