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January 2014 Client Newsletter





January 1, 2014


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 eligibility as a service.  For those not using our Scheduler, we provide it at no cost to your office (call Rich to discuss). 


~~We have noticed Horizon starting to recoup a large # of payments – though the dollar amounts are not very large.  It is our understanding that this effort is associated with managed care claims that were mistakenly paid at the traditional fee schedule.

NJ law requires that:
• The recoupment request be in writing,
• Identify the payment error, and
• Provide information regarding appeal rights.

Physicians have 45 days to appeal a recoupment request. Therefore, the payor may not take back any monies automatically until the 45 day period is over. Once an appeal is filed the payor may not recoup the monies until the appeals process has been exhausted.
MSNJ is involved & is concerned that providers have not received advanced notice of the recoupment effort, other than EOB's that list an accounts receivable report. MSNJ asked Horizon to provide additional information regarding the effort, supply physicians with formal notice of the recoupment (including appeal rights), and delay automatic recovery until the 45 day appeal period ends or the appeals process is exhausted (whichever is later).

If you have received a letter from Horizon requesting a refund, be sure to forward it to my attention ASAP – not your usual CPB contact. 

Physicians who will face financial hardship due to the recoupment should contact their network specialists to discuss the matter. 


Horizon announced during an MSNJ webinar this week that in 2014 they will be auditing the use of:
• Modifiers 24, 57 & 80.
• Inpatient consults
• Critical Care
• Prolonged services

As we have said previously, be sure to notify CPB so we can assist you with your response.  Failure to respond results in take-back of all payments, and likely being placed on pre-payment audit plus referral to their “fraud” unit.  Their auditors based their review strictly on the documentation sent so be careful to document patient visits within the 1995 or 1997 CMS Guidelines. 


Just a final reminder from CMS when a referring physician is required for a Medicare or Railroad Medicare patient.  Here is the link to verify a referring provider:

If the referring provider is not on the list, your charge(s) will not be paid by Medicare for dates of service after 1/6/14.


CPB has reviewed the 2014 CPT code changes and only one of our specialties was minimally affected. 

ICD-9 has no changes this year, but ICD-10 is looming BIG.  If you have not begun to think about coding in ICD-10 and the detailed information needed for us to do, we are now just over 10 months from implementation so you will want to be thinking seriously about it.  If you aren’t sure, feel free to give Rich a call and he will be glad to walk you thru the options.  Those with EHR programs should be in a better position if you are currently doing your coding.  Those without an EHR, also have electronic options to select ICD-10 codes.  Just call Rich about that also!

2014 Client Newsletter Archive