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November 2014 Client Newsletter




November 1, 2014

2015 Medicare Part B Deductible

Medicare has announced there will be no change to the Medicare Part B deductible for 2015.  It will remain $147. 

Payment for Transition Care Codes 99495 & 99496

We have billed for the Medicare, AmeriHealth PPO, HMO, and AmeriHealth Administrators for Transition Care codes.  These are the codes that pay a primary care physician to perform follow-up care within 7 or 14 days post discharge from inpatient care on patients for 30 days.  All are 2014 DOS’s. 

  • The PPO has paid $179.25 for 99496 with an additional $20 copay for a total of $199.25.
  • AmeriHealth Administrators paid $141.34 for 99495.  No copay was assigned. 
  • AmeriHealth HMO allowed $141.25 paid $121.25 for the 99495. 
  • Medicare Allowed $176.73 for 99495 & paid $138.55.
  • Medicare allowed $249.06 for 99496 & paid $195.26.

So overall, it does seem to pay well.


Just a reminder that to earn the PQRS incentive bonus for 2014 (and avoid the penalty), patients must be evaluated during 2014.  We have seen the most success filing via registry rather than via claims.  That has also been the experience throughout the nation.  The registry usually only requires 20 – 30 claims whereas using claims can require 50% of all of a category. With the registry, you can see while online whether you met the standard or not.  If you file early, then you have time to add more patients if needed.  Using claims is risky since you are not notified if you met the standard until you get paid – or not.  There are LOTS of companies offering a PQRS registry, but be sure to use one from the CMS approved list.    

Bilateral Cerumen Removal (69210)

Medicare strikes again!  Even tho the AMA changed the description to unilateral, CMS has decided to maintain that it will pay the same for 1 or both ears.  Medicare allows about $50 depending upon the state. 

Virtual Credit Cards - #

ERA and EFT are, under HIPAA, MANDATORY. Insurers and providers cannot opt-out. These rules took effect this year.  If the provider opts for the "credit card" (actually a Debit Card) the practice will incur a transaction fee from the card issuer of up to 3% of the payment. It is common knowledge that the insurer gets up to 50% of the fee as a kick-back. Card-based payments are NOT HIPAA compliant, but providers are allowed to opt-in.  Card-based payments cannot be unilaterally imposed by the insurer.

We suggest you tell insurers you want EFT which is less expensive – not Virtual Credit Cards (VCC).

High Deductible Plans

One of our physician clients has been on the forefront of the relevance of high deductible insurance plans.  Last week he sent an excerpt from the front page of the NY Times, October 17th edition entitled “Unable to Meet the Deductible or the Doctor.”  I have changed the patient’s name, but here are the first few paragraphs (if you are interested in a copy of the full story, email Rich):

Article by ABBY GOODNOUGH and ROBERT PEAR OCT. 17, 2014

“Patricia Smith got insurance through the Affordable Care Act this year, and with good reason: She suffered a brain hemorrhage in 2011, spending weeks in a hospital intensive care unit, and has a second, smaller aneurysm that needs monitoring.

But her new plan has a $6,000 annual deductible, meaning that Ms. Smith, who works part time at a landscaping company outside Chicago, has to pay for most of her medical services up to that amount. She is skipping this year’s brain scan and hoping for the best.

“To spend thousands of dollars just making sure it hasn’t grown?” said Ms. Smith, 61. “I don’t have that money.”

About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.”

The article continues this discussion, but here are the interesting questions raised by our client:

Some thoughts:

  1. If a child has health care through their parents jobs and has a $5,000 deductible are they insured?
  2. If a patient has a high deductible plan does the insurance company matter when making an appointment as this is essentially a market oriented cash visit?
  3. If a patient has a high deductible plan does an authorization company matter? Why are authorizations and peer to peer reviews being done when even if these are approved the patient still has to pay and the insurance company makes no payments?
  4. If a patient has a high deductible plan why would a physician authorize any Quality Assurance reviews from an insurance company/authorization company that does not make payments?
  5. Will insurance companies have relevance as time goes by when they don’t pay anything

Points to ponder!




2014 Client Newsletter Archive