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April 2014 Client Newsletter


April 1, 2014


The clear answer is that insurance should be checked each visit.

The question is - how often are you willing to either:
- Not get paid because the patient now has no insurance, but you did not know it?
- Get paid late because you did not have the right insurance when it was billed?

These days, you can verify eligibility electronically to double-check patients, although (shockingly!) insurance records may not always be accurate.  It will minimize denials & collect correct copays.

Who is the most important member of your healthcare team?  Well, everyone is important but you could make an argument that your Receptionist is when it comes to getting paid.  They are at the very beginning of the “revenue cycle.”  His/her job is usually to make appointments, greet patients, obtain patient demographics and insurance information, collect co-pays & deductibles, schedule the next appointment, etc.  Those are critical functions in gaining and keeping patients, but also in bringing in the maximum amount of money possible from those patients.  They must be comfortable making sure all information is collected and asking for co-payments or past due balances.  A pleasant, organized Receptionist is a key “cog” in the revenue cycle wheel! 


Medicare pays for Preventive services – and the patient usually has no co-insurance or deductible.  These codes represent a significant number of services to enhance patient health.  And they pay well also! 

Two documents were sent in an email on March 20, 2104 to all providers who treat Medicare patients:
• A color-coded spreadsheet of the most common PCP Medicare Preventive Medicine Codes, including their Allowed Amounts, Required Diagnoses, and Caveats.  A copy is also included in client Monthly Report packets. 
• The CMS Medicare Preventive Services Quick Reference Guide which provides additional details.
We hope the spreadsheet will help you provide additional services to your Medicare patients.

As a matter of policy, Champva has notified us that they will not cover Cerumen removal (69210) when billed with an E&M code.  Generally 69210 will only be covered now if instruments were used to remove the ear wax. 


Medicare implemented PECOS several years ago as their way for providers to submit new & updated enrollment applications.  It had problems from the start and it has steadily gotten worse in spite of “improvement.”  Several of our clients have tried to use it recently – and also experienced serious issues.  Your experience is the same as providers throughout the nation.  If you are going to do the work yourself, we recommend that you file a paper application after verifying with Medicare what application # (s) they need.  We have had good success on paper, and zero with PECOS. 


With respect to individuals enrolled in Qualified Health Plans sold through the Exchanges, the response you receive to the eligibility inquiries may be technically correct, but not always necessarily reliable.

Under the Affordable Care Act, Qualified Health Plans are prohibited from removing most individuals/families from the Qualified Health Plan’s rolls until the enrollee/family has failed to pay his/her premium for 90 days. This is referred to as the 90-day grace period. This 90-day grace period policy only applies to individuals/families who receive a subsidy from the federal government to help pay for their insurance. Individuals whose premium are not subsidized are only protected to the extent there is a state law governing such matters.

More importantly, for those individuals covered by the 90-day grace period, the Plan is only obligated to honor claims for services provided during the first 30 days of that 90-day grace period.

CMS has not provided any definitive guidance to the Health Plans in terms of how they should respond to an eligibility inquiry that occurs after the initial 30 days for these Grace Period enrollees. Technically, the individual is still enrolled; however, the plan is no longer obligated to pay the claim.

With respect to claims for services provided to these individuals, CMS recommends that the Plans hold claims for services delivered during days 31 – 90 of the Grace period and notify the provider that the claim is being held. Then, at the expiration of the 90 day period, if the enrollee still has not paid his/her premium, the plan has the option of either paying the claim or rejecting the claim. CMS says that if the plan rejects the claim, the provider can then seek payment from the individual.


AS everyone now knows, ICD-10 has been delayed until at least 10/1/15 by Congress. 

2014 Client Newsletter Archive