Search Results for: Payer Contracting
A payer audit notification can strike fear into the hearts of medical practices โ but it doesn’t have to. Discover how to respond effectively thanks to expert tips from a nationally-recognized healthcare attorney.
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Medicare Secondary Payer denials are among the top five denial reasons from Part B payers โ but they don’t have to be. This expert-led online training will help you cut MSP denials and collect faster.
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Maximize your CAQH Proview (DataSpring) provider/practice accounts to get more patients, save on administrative costs and boost how quickly and accurately you get paid. Gain actionable tactics from this expert-led online training.
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You can get more rejected claims overturned, if you know what payers really want from your appeal letters. Let nationally recognized appeals expert Christine Hall provide you with the tools you need to get more of your claims paid.
Learn MoreGet actionable steps you can put into place to ensure your provider credentialing applications move smoothly through the approval process, and help you jump into action if slowdowns occur. This online training shows you how.
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Your practice’s revenue depends on your ability to quickly, easily and efficiently track your data. Find out how to utilize Excel Pivot Tables to pin down hidden expenses and uncover revenue opportunities during his online training.
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You can get paid more for your payor contracts, if you know how. Attend this live online training to get Jill Arenaโs proven payor contracting tools that will help your practice get paid more of what it deserves.
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Avoid violating Balanced Billing Laws with step-by-step advice from expert Amanda Waesch, Esq.. She’ll help you head off preventable out-of-network, financial hardship, and write-off errors that can cost you millions in penalties.
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When onboarding a new physician into your practice, your process must be flawless. A simple mistake can result in sever reimbursement delays โ or worse, payer rule violations. With this online training you’ll get it right the first time.
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You must master the new NPPES Registry Portal changes and data requirement updates to ensure that your providers continue to get paid. Conquer the numerous Portal changes with this practical, expert-led online training.
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Join healthcare attorney Osato F. Chitou, Esq., MPH for a powerful training that shows you exactly how to use healthcare laws to your advantage โ to overturn denials, prevent audits from draining your revenue, and safeguard your practice from costly legal pitfalls.
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Credentialing and enrollment 101 for physician practices. Step-by-step strategies to help you master credentialing and enrollment basics to avoid errors and ensure that your revenue keeps flowing.
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A payer audit notification can strike fear into the hearts of medical practices โ but it doesn’t have to. Discover how to respond effectively thanks to expert tips from a nationally-recognized healthcare attorney.
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The chances that your practice will face a Medicare audit are higher than ever. The latest stats show that payer audits quadrupled last year. Attend this training to make sure youโre ready when Medicare auditors knock on your door.
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Get payers to abide by their contract promises to reduce payment delays, claim denials, authorization holdups, provider enrollment barriers, etc. Find out how. Sign up for this training presented by expert David Zetter.
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Medicare Secondary Payer denials are among the top five denial reasons from Part B payers โ but they don’t have to be. This expert-led online training will help you cut MSP denials and collect faster.
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About 83% of your non-Medicare/Medicaid claims are governed by ERISA regulations. However, payers donโt want you to know how to apply these rules to take control of your reimbursement. This training shows you how.
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Terminating a payer contract might seem straightforward, but the minefield that follows can be a legal and regulatory nightmare. Protect your practice against the fallout by attending this expert-led 60-minute online training.
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Donโt give up on your under reimbursing contracts due to lack of payer response to your negotiation requests. Learn how to improve payer contract negotiation results. Get the tools you need to secure higher rates and better terms.
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Failing to collect copays and deductibles can get you into just as much trouble as collecting them incorrectly.ย Protect your practice against costly violations with the actionable tactics in this healthcare attorney-led online training.
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Utilizing locum tenens providers can be a huge benefit to your practice. But it can also be a legal nightmare if you fail to comply with the complex rules.ย Get how-to help from legal expert Rachel Rose during this training.
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With a few simple changes, you can streamline your Good Faith Estimate processes, head off compliance issues, negotiate higher payer rates and get paid more. Healthcare attorney Amanda Waesch, Esq., shows you how.
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You can negotiate with third-party payers to increase your reimbursement – if you know how. This expert-leg online training will provide you with step-by-step contract negotiation strategies that word. Start getting paid more today.
Learn MoreThe physician credentialing process is a complicated collection of hoops to jump through and moving parts to track. Get a step-by-step, proven process to help you keep cash flowing.
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Auditors recently found that more than half of telehealth services for mental health are billed incorrectly. This online training will help you stop these common coding & billing errors to collect more for these complex claims.
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Insurance companies are cracking down on how you document therapy progress notes. Even simple mistakes can greatly reduce your ability to get paid, lead to payer audits, recoupments, and penalties.ย This training can help.
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Combat non-Medicare and Non-Medicaid denials with proven ERISA appeal letter writing strategies. Online training helps you get more claims paid.
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Last-minute cancellations and patient no-shows can destroy your dental practice’s profitability and upend your carefully planned daily schedule. Discover how to handle these issues
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Get payers to overturn more of your denied claims so that you can receive more of the reimbursement you are due. Expert reveals proven appeal letter writing strategies and templates to quickly get more of your denied claims paid.
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Both commercial and government payers make provider enrollment more complex than it needs to be, but you’ve got an expert on your side. Get the proven tactics you need to providers approved faster and start getting paid sooner.
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Uncover language in your managed care contracts that can help your practice get paid more and avoid hidden pitfalls. Healthcare attorney Michael R. Lowe shows you how to make your managed care contracts work for you.
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Medical records are legal documents that support every aspect of patient care, and one medical documentation mistake can get you audited. Then violations, penalties, and unpaid claims follow. Protect yourself with this online training.
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Avoid common/costly errors and meet requirements of provider credentialing and enrollment online sites with practical advice from national expert, Tracey Tokheim. Improve your accuracy and results while reducing headaches.
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Get insurance carriers to reimburse you more. The key is in how you negotiate your managed care contract. Get expert insider negotiation strategies that give you a huge advantage during your contract negotiations.
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You can collect (and keep!) more money from your claims. During this training, two healthcare attorneys will walk you through how to fight back against reduced payer ERISA claim payments and get paid more of what you are due.
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CMS has plowed through their appeals backlog, opening their doors to reimbursing your claims FASTER. Get expert tips on winning appeals strategies that convince Medicare and private payers to give you the cash you deserve.
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You can eliminate enrollment delays, get paid faster, and avoid re-enrollment disasters by getting your mid-sized to large practice set up to perform delegated credentialing. Get expert tactics on getting it right the first time.
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Modifier 59 is among the most frequently used modifiers, but also one of the most often denied. Halt those denials and bring in the pay your practice deserves with these essential modifier tips.
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When your practice gets an insurance demand letter, it’s no time to panic. Instead, create your response strategy with actionable tips from expert Sean Weiss during this essential online training event.
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Get paid more for treating patients with chronic pain โ learn to correctly apply new 2023 codes G3002 & G3003. Online training shows you how to code these services (G3002/G3003) more accurately & get higher reimbursement.
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Before you start charging patients extra for the additional time it takes to refill prescriptions, you must have a handle on how to implement these fees correctly. You can compliantly get paid for prescription refills – find out how.
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Correctly billing self-pay patients is more important now than ever. Self-pay patient numbers are rising due to the May 11 PHE expiration. This training will help comply with self-pay billing rules and keep you out of trouble with the Feds.
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Avoid delaying and losing reimbursements. Streamline your credentialing and enrollment process – more efficiently manage multiple providers and locations NPIs, Tax Ids, delegated agreements, and more. Proven online training.
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Quickly get more of your denied claims paid with proven payer appeal strategies. The key is mastering the nuances of your appeals process by cutting through the red tape. Find out how…
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Unfortunately, getting and keeping your dentists enrolled and credentialed in both commercial and government insurance plans is a necessary evil that can take hours, even with the ADA CAQH ProView online portal. The average dentist participates with 30 networks, and with each requiring credentialing every three years, that could mean youโre working on at least[...]
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Complying with recent changes when billing for out-of-network and uninsured patients is more complicated due to recent rule changes. Learn how to comply before the audits begin. Sign up for online training today.
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You can get paid for denied out-of-network services. The catch is that you must master CMSโ recently implemented IDR process. Get proven strategies to correctly utilize this new process to overturn these previously unpaid claims.
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Get the tactics you need to make utilizing the CMS PECOS online Medicare enrollment and credentialing system less confusing and more accurate. Attend this training for practical, expert advice so you get it right the first time.
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Billing patient directly may be your best bet of getting paid for commercial payer non-covered services, but you should NEVER do so without the correct forms on file. Attend online training to master non-covered services billing.
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Payers include excessive administrative burdens in managed care contracts that delay your reimbursements and add hours of extra processing time for your staff. Get negotiation tactics to cut these burdens & save time and money.
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How you manage your outsourced medical billing vendor relationship can seriously increase your claimsโ reimbursement and decrease your financial and legal risk. Expert Owen Dahlโs training will show you how.
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Your practice is required to create and validate your provider directory listings or be faced with getting kicked off the panel. This online training will help comply with these No Surprises Act rules and keep your revenue flowing.
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There is a lot riding on the accuracy of the claims you submit. Missing even one step in the billing process can result in dire consequences โ significant reductions in claim reimbursement, increased denials, overpayments/recoupments, refunds, and ultimately audits that lead to massive fines and penalties. From pre-authorizing procedures and collecting copays to appealing claims[...]
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You depend on accurate medical coding to keep your practice’s reimbursement flowing โ and though it’s not vital for everyone to know HOW to code, it is important to get a basic understanding of coding to preserve your income.
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Outpatient payer audits are skyrocketing in 2022. To survive you must be prepared. Get practical, real-word strategies to help you identify and resolve medical record hot zones in your practice โ before you get audited.
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By making you use virtual credit cards for your reimbursement payments, payers are passing their processing fees on to you. You can refuse and keep more of the money your practice is due. This training will show you how.
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If you want to get paid, prior authorizations are a necessary evil. They put an intense burden on your practice, staff, patients, and you.ย You can reduce the time they take and improve your overall approval rate with some expert help.
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Attorney provides practical advice on how you can reduce Medicaid audit triggers at your practice, more effectively respond to Medicaid audit notices and documentation requests to significantly reduce overpayment demands.
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Proven negotiation strategies to use before you sign your next physician/hospital service agreement. This expert training will help you get paid more and protect yourself and your practice against federal and state violations.
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Commercial payers are taking their enrollment and credentialing deadlines more serious than ever. Missing a deadline by even a day can have serious consequences for your practice.
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Get proven strategies to help you write an appeal letter template that will get more of your denied claims overturned and improve the reimbursement you receive.ย ย Register for this expert-led online training today to find out how.
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Out-of-network collections are complicated. Successfully negotiating with payers, communicating with patients and getting paid what you are due is possible if you know how. Sign up for this expert-lead online training to find out how.
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Master proven strategies to get payors to overturn your contract deactivation.ย This expert-led online training will walk you through each step and help you head off lost patients by reactivating your contract.
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Applying E/M modifiers incorrectly can seriously cut your revenue, especially considering this yearโs massive 2021 E/M changes.ย Donโt file another E/M claim without ensuring youโve got it right. Sign up for this online training today.
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Terminating a payer contract may feel like youโre slaying a dragon but do so for the wrong reasons and you could unintentionally slash your revenue too. Get the strategies you need to decide when you should walk or stay.
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Get proven appeal strategies to help you overturn more third-party-payer denials and avoid claim reimbursement reductions. During this live online training, healthcare attorney tells you how.
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Avoid common CMS 1500 Claim Form error that lead to delayed payments or completely rejected claims. Expert biller provides you with step-by-step advice that will get you paid faster and more accurately.
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Without a recall strategy, many of your patients would never schedule their next visit. This lack of recurring patient care puts your practice at risk of losing hundreds of thousands of dollars in lost revenueโฆ
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Getting and keeping your providers enrolled in the most popular payer networks is the only way to ensure the success of your practice. However, it can be complicated and time consuming, but it doesnโt have to beโฆ
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There is a lot riding on the accuracy of the claims you submit. Missing even one step in the billing process can result in dire consequences – significant reductions in reimbursement, increased denials, and ultimatelyโฆ
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As Medicare and private payers continue to go after reimbursement paid in error, the chances youโll get audited has increased. Auditors can dig through your previously filed claims for a โlook back periodโ of 6 YEARSโฆ
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Open the doors of those “closed” and โnarrowedโ insurance panels that will most benefit your practice. Donโt walk away from payers when they deny you access to the patients you want. Use these proven tactics to get…
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…can be billed in-network, create a payer-by-payer readiness checklist. Document credentialing status, enrollment status, effective date, group affiliation or reassignment, and confirmation from the payer. Make Accurate Provider Data a…
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…the cost-benefit calculation entirely. For years, the $115-per-party fee made low-dollar claim disputes a losing proposition before the process even started. If a payer underpaid a $200 claim, spending $115…
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…payer rules, you’re not alone. Many physician practices face these challenges as MA enrollment grows nationwide. The good news: when you understand payer expectations, strengthen documentation, and follow good-faith billing…
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…services, payer integrity programs frequently focus their automated review efforts on these claims. Many payers now use layered review systems that combine automated edits, machine learning models, natural language processing…
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…they’re paying claims directly out of their own pocket. The carrier is essentially renting out their network and processing paperwork. They’re an administrator, not the actual payer. That distinction matters…
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…for outpatient and professional claims and the discharge date for inpatient services. Using an outdated code after the implementation date can trigger immediate clearinghouse rejections and payer denials. For physician…
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…payer or a clearinghouse vendor is extremely difficult to distinguish from a legitimate message — especially when your biller is processing hundreds of claims a day under deadline pressure. One…
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…only reliable way to bypass payer delay triggers and keep revenue flowing on schedule.” As you tighten up your internal processes, the next challenge is what happens on the payer…
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…Training Leader’s 3-Month All-Access Training Pass, your entire team receives unlimited access to hundreds of expert-led trainings covering Medicare reimbursement, billing and coding updates, compliance requirements, payer contracting, telehealth regulations,…
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…claim denial trends Aging accounts receivable Prior authorization delays Coding accuracy concerns Documentation deficiencies Patient collection performance Compliance updates Payer policy changes These discussions directly affect your practice’s revenue and…
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…Inspector General (OIG), Medicare contractors, and commercial payers all use sophisticated analytics to identify unusual billing patterns and potential compliance concerns. Fortunately, you don’t have to overhaul your entire practice…
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…Payer Adjudication Learn Why Claims Get Denied When payers process claims, they compare submitted information against coverage policies and medical necessity rules. Claims may be: Paid Rejected Denied Pended for…
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…Medicaid, and commercial payers don’t all follow the same modifier logic. Some payers restrict Modifier 59 use to specific audit scenarios. Check each payer’s policy manual before finalizing the claim….
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…today’s healthcare environment, tighter reimbursements, rising patient balances, and increased payer scrutiny mean your revenue cycle can either strengthen your practice—or quietly drain it. The good news is that most…
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…no no field_60a298f4110c3 field_5d261ad51e5f8 22083 Medicare Secondary Payer billing How to Bill Medicare Secondary Payer Correctly How to Bill Medicare Secondary Payer Correctly Learn how Medicare determines primary versus secondary…
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…windows payers require. Step 3: Audit for Timeliness and Amendments Authentication isn’t just about who signed — it also concerns when. Before you lock a record for billing, you need…
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…results were received Time spent reviewing them Your clinical interpretation Actions taken (med changes, follow-ups, referrals) Without this level of detail, payers may deny the claim or question medical necessity….
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…compliance plan annually. Train every employee—not just coders and billers. Monitor billing trends before payers identify them. Strategy 1: Automate OIG Exclusion Screening One of the easiest compliance improvements you…
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…proven best practices, you can reduce credentialing delays, improve payer communication, and make sure your providers are ready to participate with insurance networks as quickly as possible. Start With Accurate…
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…and payer enrollment. Incomplete employee training documentation can create problems during audits. Poor communication between departments often causes preventable compliance failures. According to the Centers for Medicare & Medicaid Services…
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…provider documents incomplete medical necessity. Coding doesn’t receive clarification before the claim is submitted. A prior authorization expires because no one followed up. A payer policy change isn’t communicated to…
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…Your Practice Faces Mastering ABNs is just one piece of protecting your practice’s revenue. Today’s medical practices are facing constant changes to Medicare rules, payer requirements, coding regulations, compliance mandates,…
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…management, revenue cycle optimization, payer contracting, and more. Get practical guidance your entire team can implement immediately to improve collections, reduce administrative burdens, and increase profitability. 1781883993:13615 13615 240920…
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…practice locations, malpractice insurance details, and required disclosures. Every field matters. Incomplete profiles do not just slow down payer access; they block it entirely. Payers cannot pull data from a…
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…administrative dismissals or delayed reimbursement. Staff members should routinely verify payer information, maintain complete claim documentation, and ensure all records align with federal submission requirements. Investing in ongoing revenue cycle…
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…Matter More in Value-Based Care Healthcare reimbursement is no longer based only on the volume of services provided. Payers increasingly evaluate medical practices based on outcomes, quality metrics, risk adjustment,…
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…Even when intent is not present, patterns of waste or abuse can still trigger payer scrutiny. Teaching your team these distinctions helps them recognize risks before they escalate. Know the…
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…Medicare and other payers, document medical necessity, and manage your revenue cycle. By preparing early, you can reduce compliance risks and position your practice for smoother claims processing and stronger…
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…both Medicare and Medicaid present unique billing challenges. Medicare typically serves as the primary payer, while Medicaid functions as the secondary payer. If Medicare claims are not processed correctly or…
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…leads to underbilling, denied claims, and lost revenue. The reality? Most practices leave money on the table simply because documentation and modifier usage don’t align with payer expectations. Learn exactly…
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…care while remaining compliant with Medicare, Medicaid, and commercial payer requirements. Compliance Is Everyone’s Responsibility The strongest compliance programs are built on a culture where every employee understands their role…
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…practice to risk. Action Step: Separate minor records in your system and apply extended retention rules automatically. Are You Following Payer Contract Requirements? Many payer contracts include specific record retention…
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…Provider-specific downcoding trends Documentation weaknesses Payer-specific issues Internal audits can dramatically improve reimbursement accuracy while reducing compliance exposure. How to Respond When Claims Are Downcoded If a payer improperly downcodes…
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…systems. The government is no longer waiting for whistleblower complaints or payer disputes to uncover problems. Instead, agencies are proactively using billing data, utilization trends, EHR records, and artificial intelligence…
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…payer information, your practice risks claim denials, billing delays, and frustrated patients. Insurance verification mistakes frequently create revenue cycle problems that impact the entire office. Incorrect patient demographics or insurance…
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…that many physician practices are too busy handling staffing shortages, reimbursement cuts, payer denials, and operational fires to actually monitor those warning signs. That is exactly why the HHS Office…
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…more time on appeals, your cash flow slows down, and provider frustration increases. How Downcoding Actually Works (What Payers Are Looking At) Algorithm-Driven Claim Reviews Payers use proprietary algorithms to…
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…common, which can create operational headaches for providers and staff. Your practice should not simply accept denials without review. Instead: Track denial patterns Monitor repeated payer behavior Appeal inappropriate denials…
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…Also Matter Your payer contracts often include specific rules about handling overpayments. If you ignore these requirements, you risk recoupments, contract violations, or even termination. You should regularly review payer…
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…(Hint: It’s Not Your Vendor) Your clearinghouse doesn’t own your claims. Your payer doesn’t own your claims. The provider does. According to CMS billing guidance, providers are responsible for ensuring…
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…of medical necessity. To overturn these: Show symptoms and functional limitations Include diagnostic evidence Document failed conservative therapy Align with payer policies Your argument should directly match the payer’s coverage…
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…E/M downcoding. Payers are increasingly using automated claim review systems, predictive analytics, and artificial intelligence tools to evaluate Evaluation and Management (E/M) claims. While automation may improve payer efficiency, it…
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…missing eligibility information, or incorrect payer coordination details. This creates avoidable claim denials, rework, and delayed payments. Your billing team may also spend hours manually researching eligibility issues that could…
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…resolving discrepancies early—can help prevent unnecessary delays. Payer Enrollment (Where Revenue Actually Starts) Credentialing alone does not get you paid—you must also complete payer enrollment. This is the step where…
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…handle higher volumes of denials efficiently. When used correctly, templates improve consistency while reducing staff burnout. Stay Compliant with Legal & Payer Requirements Ignoring payer rules can cost you—big time….
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…Payers Expect (and Audit For) Payers—including CMS and private insurers—are actively auditing Modifier 25 usage. Programs like CERT and Targeted Probe and Educate (TPE) specifically review E/M billing accuracy. The…
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…— not your practice. However, the law gives you leverage. When a payer’s policies create barriers to mental health treatment that aren’t applied equally to physical health services, those policies…
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…onboarding Improved cash flow Fewer claim denials Better compliance Stronger payer relationships Credentialing efficiency also supports network participation and expansion. CMS and payer systems rely on accurate provider data to…
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…— and your revenue — up for failure. When your staff understands payer basics, they can: Answer patient questions with confidence Capture accurate demographic and insurance information Build trust and…
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…should: Review payer-specific billing guidelines regularly Confirm POS requirements for telehealth and outpatient services Train your team on payer differences If you assume all payers follow the same rules, you…
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…depends on how effectively you handle payer disputes. That’s where the Independent Dispute Resolution (IDR) process comes in. It gives you a structured way to challenge underpayments and fight for…
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If your team is sending large patient balances to statements, you’re already behind. The biggest shift in healthcare revenue isn’t payer behavior — it’s patient responsibility. More of your revenue…
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…it incorrectly, you risk: Hiring unqualified providers Failing audits Losing payer contracts Facing legal and financial penalties PSV is not optional—it is a compliance requirement and a risk management strategy….
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…compliance strategies with the All-Access Pass. 1774457751:13615 13615 179419 no no field_60a298f4110c3 field_5d261ad51e5f8 22083 healthcare payer audit response How to Respond to Healthcare Payer Audits Healthcare payer audits are…
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…Revenue by Payer You can start with one of the most important financial questions in your practice: Which payers are actually paying you—and how well? Here’s how to build a…
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…practical strategies by watching the Improve POS Coding training. 1774894640:13615 13615 207275 no no field_60a298f4110c3 field_5d261ad51e5f8 22083 healthcare payer audit response How to Respond to Healthcare Payer Audits Healthcare…
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…necessity. Always confirm payer acceptance before billing. โ Apply telehealth modifiers properly Modifier -95 typically indicates synchronous telehealth services with audio-video interaction. Some payers require additional modifiers or documentation. โ…
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… 1774457154:13615 13615 219766 no no field_60a298f4110c3 field_5d261ad51e5f8 22083 healthcare payer audit response How to Respond to Healthcare Payer Audits Healthcare payer audits are increasing in 2026, making proper audit…
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…payers, claims can be denied, payments delayed, or billing privileges revoked. CMS continues to enforce strict screening, verification, and reporting requirements under the Medicare provider enrollment regulations (42 CFR §…
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…necessity. Without this documentation, your claims may be denied or recouped during audits. A well-written policy also creates consistency across your team and ensures you can respond quickly to payer…
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…strong QAPI program helps identify problems early and implement sustainable solutions. Over time, these improvements can lead to fewer patient complaints, fewer claim denials, and stronger payer relationships. Why CMS…
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If your practice submits claims to Medicare or commercial payers, selecting the correct Place of Service (POS) code is essential. One small coding error can trigger claim denials, payment reductions,…
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…and operations teams use them to see how schedules, productivity, and payer behavior affect outcomes. When your reports are shared across the practice, everyone understands the true impact of their…
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What Modifier 25 Means (And Why It Matters for Your Practice) Modifier 25 tells payers you provided a significant, separately identifiable Evaluation & Management (E/M) service on the same day…
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If your practice is struggling with denied claims, delayed payments, or unpredictable cash flow, the issue often isn’t your EHR or your payer contracts — it’s training. Billing rules, payer…
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…on medical necessity, documentation, and whether the service is truly “significant and separately identifiable.” If you get this wrong, you risk denials, recoupments, patient billing complaints, and even payer scrutiny…
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…trigger payer review or regulatory inquiry. Practices with strong documentation, signed disclosures, and updated financial policies resolve issues more smoothly. Your best defense is proactive compliance — not reactive correction….
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…that reality helps your team stop blaming themselves — and start responding strategically. How Payer Interference Impacts Patient Care and Staff Burnout When payers delay or deny claims, your staff…
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…single downcoded visit may reduce reimbursement by tens or hundreds of dollars, depending on payer contracts. When this happens repeatedly — across multiple providers and payers — the cumulative loss…
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…knowing what payers expect, how to document correctly, and how to defend your claims with confidence. Why Payer Audits Are Increasing — and Why Your Practice Is a Target Payers…
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…support eligibility, billing accuracy, and medical necessity for virtual services. When your team follows consistent documentation standards across Medicare, Medicaid, and commercial payers, you protect reimbursement while maintaining compliance. Document…
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…on increasing reimbursement through smarter payer contracting. In this training, you’ll discover: Where payer contracts quietly limit reimbursement How to strengthen your negotiating position What documentation and data payers expect…
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If your practice bills insurance, enrolls providers, or participates in Medicare, Medicaid, or commercial payer networks, the NPPES portal plays a critical role in whether your claims get paid. When…
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…compliance in 2026. Billing requirements, payer policies, and documentation standards continue to evolve. Get complete 2026 telehealth billing and compliance guidance by watching this on-demand training. This training helps ensure…
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…wrong device code can result in underpayment or recoupment. Always confirm payer-specific guidance, especially for Medicare Advantage plans. How to Combine RPM with CCM and E&M—Without Risk RPM services may…
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…how you schedule patients, bill payers, document visits, and maintain continuity of care. That uncertainty is why the American Medical Association (AMA) is pushing lawmakers to make pandemic-era telehealth rules…
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…payer processing mistakes early in the year and must actively audit remittances instead of assuming accuracy. Action for staff: Create or update a provider list that clearly identifies QP vs….
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…so does the volume of prior authorization requests, claim scrubbing requirements, and payer-specific rules your team must follow. When MA plans: Delay care Misapply payer policies Create excessive prior authorization…
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…These issues typically happen because information was missed, documentation was incomplete, or payer rules weren’t followed exactly. Understanding these root causes is the first step to fixing them. The most…
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…copies and not originals. Follow up Frequently If the provider credentialing process seems to be moving slowly, get the contact information for someone at the payer’s office and follow up…
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…confirm before performing these services and billing them to your payer. Confirm Which Payer is Primary More than 6,000 denials happen every year at CGS Medicare because the wrong payer…
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Another day, another downcoding policy to grapple with. And while that’s unfortunately the reality in today’s healthcare world, the latest news from Aetna isn’t all bad. The payer has issued…
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…or seeing your claims downcoded. Not every outlier letter means you’ll face lost revenue, but it can still be upsetting. Check out a few steps to take if your payer…
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…encounter for code selection, 40 minutes must be met or exceeded) is among the codes that Cigna has targeted for automatic downcodes in certain instances. Payers will reimburse about $155…
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…records, billing and coding practices, claims, documentation and payer reimbursement (if the audit is retrospective). Look for correct use of coding and detailed patient documentation as you perform the audit….
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…payable after the government reopens, then your payer will reimburse you for these visits after the claims hold is lifted. If CMS’ claims hold is taking a bite out of…
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…you’re appealing. Right near the beginning of the letter you’ll want to tell the payer why you believe they denied your claim incorrectly. Common reasons for appealing include: The payer’s…
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…appeal with the correct information, but your best bet is to ensure you don’t have these problems up front. Missing the Filing Deadline Missing your payer’s filing date by just…
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…Up Claims Reviews This is a good time to launch prospective claim reviews, meaning you scrutinize your claims before sending them to your payer. This gives you a chance to…
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Cigna’s new E/M downcoding policy — which will apply to certain high-level E/M claims — takes effect next week. And as the Oct. 1 implementation date approaches, the payer has…
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…invaluable—it’s about sharing insights that directly impact your work. A quick forum thread on handling payer denials, for example, could save your practice time and money. Organizations like PAHCOM foster…
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…what happened. They’ll work with you to identify how many claims were affected, how much money you’ll need to reimburse to the payer, and how to go about self-reporting the…
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…payers, you’ll submit one of the CMS-covered telehealth codes. For instance, you can report an established patient E/M visit performed over telehealth with a code from the 99211-99215 series, depending…
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…If CMS or another payer asks for proof that you complied with the training requirements, you’ll need to have the documentation readily accessible. This means storing it in your practice…
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…the same insurer, their copayments may not be the same because of the contract their employer has with the payer. Plus, the copay may be waived for certain preventive services,…
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…each category. Any payer that falls outside of the average should be contacted. For instance, if your average payment speed is 30 days, but Payer A is taking 56 days…
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Dr. Lopez’s busy orthopedic practice submits hundreds of claims every week. But with denials creeping up, the billing team is constantly resubmitting claims. One front-desk employee, unfamiliar with payer rules,…
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…the roles of staff members who take care of payer operations and finances. Nursing Staff Pay Soars Practices also needed more incentives than ever to hire and retain nursing staff…
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…laws and payer contracts. In some cases, you’re perfectly within your rights to offer professional courtesy discounts. Keep these rules in mind as you navigate your path. Don’t Offer Discounts…
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…out a few key strategies that will help you preserve your Medicare Secondary Payer reimbursement. What Is Medicare Secondary Payer? When Medicare isn’t the primary payer for a patient’s healthcare…
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…new patient; 65 years and older) as well as +99459. Track Payer Policies You may also still be able to report 99459 with E/M codes for payers besides Cigna. Always…
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…is in the hospital, the concept of incident to doesn’t apply. “Hospital and skilled nursing facility services cannot be billed as incident to at any time,” says Part B payer…
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…the payer. For instance, “I’m afraid your insurance company requires us to collect copayments at the time of service.” Or if the patient asks you if they can figure out…
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…get paid for the new APCM codes that Medicare payers began accepting this year. 1. You Must Have Documented Consent Before you begin performing APCM services, you need to get…
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…your payer contract to write off copayments — so what can you do? Check out what the law says, and when you can and cannot offer financial hardship discounts to…
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…to that payer. 3. The Person Handling Medicare Appeals Isn’t Authorized Medicare claims can only be filed by people with a financial interest in the claim. This includes the patient,…
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…should bill the locum’s services using the NPI of the doctor that the locum is filling in for. Keep in mind that there are certain payers that may ask you…
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…NCCI does not include an edit bundling these two codes, which means Medicare payers should allow you to bill them together. Check What Payers Say You should always consult your…
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…LeadGenSKU 1745499419:44988 44988 253331 no no field_60a298f4110c3 field_5d261ad51e5f8 22083 Payer contract 3 Considerations to Make Before Dropping a Payer Terminating a payer contract may need to be done once in…
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…Patient Informed Consent Nearly every payer you’ll be billing in 2025 has a requirement that you get consent from the patient before performing your services over telehealth. Once the patient…
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…but since only one of them is billing G0556 in a single month, the Medicare payer should still reimburse the practice for the care. You’ll collect about $15 for G0556,…
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…may look like, and will give you stronger negotiating power when you get to the table with your payers. 2. Accepting Unclear Contract Terms Payers go out of their way…
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…the claim amounts and may even be subject to fines and penalties. For instance, if you submit a claim for removing impacted cerumen but the payer reads your documentation and…
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…in submitting claims to outdated, expired or lapsed health insurers. By the time you realize you sent a claim to the wrong payer, the patient is gone and you can’t…
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…Medicare credentialing applications through the system quickly. 1. Develop a Check-in Schedule Most payers will share their average processing time for complete Medicare credentialing applications, and once you get that…
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Most providers must go through the Medicare revalidation process every five years, and if you don’t do it correctly, you could seriously harm your ability to collect from Medicare payers….
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…to ensure the payer doesn’t need more information from you. Always track the application and confirm that it’s moving through the process well. 5. Failing to Follow Up on Requests…
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…office staff then thinks these deadlines are written in stone. But the reality is that the insurer maintains these tight deadlines because they’re favorable to the payer, not to your…
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…should submit their Medicare claim using POS 66. Place of Service Codes Affect Reimbursement Your payer may adjust the amount of reimbursement you receive based on which place of service…
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When your provider talks to patient on the phone, you may worry that your payer won’t reimburse you appropriately for the visit, even though it takes just as much medical…
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…Healthcare Practice Advisor. This field is hidden when viewing the form LeadGenSKU 1729471530:22818 22818 245685 1729471521 no no field_60a298f4110c3 field_5d261ad51e5f8 22083 Managed care contracting 8 Managed Care Contracting Strategies Lead…
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…one payer wants to limit practices from collecting for this service in some circumstances. Read on to get the lowdown on how a new decision by UnitedHealthcare Commercial will change…
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…a missing CPT code, an undated progress note, or another issue that requires you to pay back what you received from payers. However, you may learn a few lessons if…
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…number(s) The patient’s payer ID number The patient’s date of birth 3. Share the Payer’s Own Policy The best way to support your appeal is to show the payer not…
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…Must Be Face-to-Face Remember that reporting 99211 requires that the patient is established and that the encounter is face-to-face. Depending on the payer, “face-to-face” may refer to an in-person visit…
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…so they shouldn’t be ignored. 5. Don’t Alter the Medical Records After Receiving the Audit Notice Never change the records before sending them to the payers. However, if there are…
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…For your standard outpatient telehealth claims, CMS no longer requires modifier 95 to be appended to the corresponding CPT code. Keep in mind, however, that other payers may still want…
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…seeing your prior authorization requests get denied, check out three tips that may help you improve your odds of success. 1. First, Read the Payer Policy From Beginning to End…
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…and myriad other reasons. Your front desk team should be able to help patients walk through the EOB line by line to help them understand what the payer is trying…
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…specific details within your claim that match the requirements within the payer policy. Sending an appeal letter that simply states, “This claim shouldn’t have been denied because we met your…
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…demand letter, you should analyze whether the payer is correct in suggesting that you owe them money. Take a look at the claim in question, determine whether you really did…
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…patient, that could raise a red flag with payers and auditors. This includes such examples as: Providers calling patients as an unplanned follow up within the same week as a…
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…it rather than waiting for a payer to tell you what’s causing the delay. Payers will always push the envelope in terms of timelines and denials, so it’s up to…
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…but NGS has clarified both those issues. “There are no frequency or duration limitations on G2211,” the payer said. “Medical necessity is the primary factor in considering the use of…
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…Information It’s very important to take note of the contact information on the card, since many payers will have different phone numbers and claims addresses depending on where the patient…
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…do not routinely waive or write off copays and deductibles. This type of conduct raises red flags and is likely to violate your payer contracts. Here’s why: The patient’s portion…
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…Claims Now How you handle your claims for G2211 now will depend on whether you’ve already sent them to your payer or not, and whether you’ve seen denials. If you’ve…
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…Modifier, Condition Code 45 Depending on your payer, even the above ICD-10-CM codes may not help you collect for your claim if the insurer has gender-specific edits in place. Therefore,…
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…payer can request is to investigate who’s asking. Although this may seem simple, the reality is that insurers often ask third-party organizations to do their audits for them. For instance,…
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…RT and LT Modifiers For Bilateral Procedures In some situations, your provider may need to tell payers where on the body they performed a service, as a way to curb…
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…with the patient. That means the payer will ask for the reimbursement back for what they paid the practice for this service. Avoid this error: Never submit a claim if…
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…$44, while 71045 will net you another $26, totaling $77 for the two codes together. Even if the payer takes 50 percent off of 71045 for the multiple procedure reduction,…
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…CMS also found illegible documentation and missing documentation. This is a good reminder to ensure that all documentation is clear, valid and legible, and that you submit everything the payer…
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Handling payer contract negotiations is never simple, and one area that many practices find particularly stressful is how to respond when a payer immediately says “no” to the terms you’re…
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…some time, take a close look at your claims and ensure that you are following all the payer guidelines, submitting the right codes and confirming that patients qualify for these…
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…and money later because you were unable to lay the proper foundation for ERISA appeals. If you ever do get into a dispute with a payer and you want to…
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…accurately — and because CPT modifiers are often tied to actual dollars, some payers are scrutinizing them to ensure they aren’t being abused. Check out three ways payers are keeping…
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…to know and understand your payer policies. Medicare local coverage decisions (LCDs) are the payers’ bible, so they should be yours as well. When payers get a claim (or an…
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…do, looking up the average pay for that code from the payer, and determining what the patient’s portion of the bill will be based on their coverage and plan. This…
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Before your practice can get paid for your providers’ services, those clinicians must go through the payer enrollment process, which has multiple credentialing steps that can take upwards of six…
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…healthcare attorney to make sure. Are You In-Network With the Payer? If you’re an in-network provider with the patient’s insurer, then your practice has agreed to accept the fee schedule…
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…a strong chance of payers reversing their denial decisions. Your best bet in setting up your insurance appeals for success will be to make sure they’re in by the deadline….
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…every time so you can avoid OIG scrutiny and potential chargebacks. 1. Create a Payer Cheat Sheet As most coders and billers are aware, every payer has different requirements when…
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As most medical practices are aware, the government is the largest healthcare payer in the United States, and the country works hard to protect the funds that go out to…
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…how the modifier worked. Unfortunately, some practices aren’t yet using modifier JZ, which could mean trouble starting in October—at which point Medicare payers will start denying claims that don’t include…
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…help you assess the Telehealth Toolkit and use it to your advantage. Check the Five Key Payer Analysis Areas As part of the toolkit, the OIG advises payers to review…
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Once you’ve scheduled an insurance contract negotiation meeting with payers, you can’t simply breeze into the room without significant preparation. The best way to have the payer accept your terms…
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…include charges for coinsurance or for services they wanted that aren’t covered by the payer. Now that those services have been rendered, you can ask them to pay the balance…
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…lose those patients. If, for instance, just three of your 1,000 patients are covered by that payer, you likely have the upper hand in negotiations, because the payer knows you…
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…notes to support the significant and separately identifiable E/M service you’re submitting. Cigna originally tried to roll out this policy a year ago, but after significant pushback, the payer said…
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…a prior authorization from the beneficiary’s MA plan, the payer must prove that it has good cause to later deny that procedure, item or service down the road. This is…
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…clear whether these relaxed telehealth guidelines around mental health services will become permanent, it’s a good idea to keep an idea on your payer’s coverage determinations so you’re aware of…
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…charge patients when they fail to present for an appointment. Keep in mind, however, that Medicare and many other payers include a catch in their no-show fee rule: You must…
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…code must have modifier FS appended to it. This tells the payer that even though you’re reporting under the NPI of one particular provider, the actual visit was performed by…
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When a recovery audit contractor (RAC) decides to audit your practice, you must cooperate, or you can be excluded from Medicare or cut off from reimbursement. It’s also important not…
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…payers take back therapists’ pay, so it’s important to adhere to. 10. Using Templates with Predefined Check Boxes, Answers Some therapists use documentation templates that include predefined answers, with check…
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If you were curious about whether the OIG had stepped up Medicaid audits as the pandemic’s effects began to wane, it’s time to stop wondering. The agency finalized 1,327 convictions…
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…to negotiating with insurers, do your homework and find out what the payer’s priorities are. For example, suppose the payer has an incentive program to reward practices whose patients present…
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…in hearing more about all-cash medical practices? Watch as healthcare attorney Amanda Waesch, Esq., leads you through the ins and outs of the payer rules around this topic. During her…
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…patient has both Medicare and Medicaid is to ask them, and then verify with the payers. This is not as easy as it sounds, since patients may not realize how…
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…all times. 5. Payer Requirements Because the front desk team often requests copays, informs patients of deductibles, and works with insurers on preapprovals, it’s essential that your staffers understand payer…
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…Payer Responses Although the OIG has noted its position on prompt pay discounting when it comes to patients under federal healthcare programs like Medicare and Medicaid, private payers may not…
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…information. This note fails to address the patient’s chief complaint, an explanation of what was performed, or how long the doctor met with the patient. That means the payer will…
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…you don’t get your providers enrolled and credentialed swiftly, they could be terminated from payer networks and dropped from hospital admitting rolls. Plus, you’ll be paying providers their salaries even…
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…about to change, depending on your payer. Discover when you can report two evaluation and management codes, and when you should consolidate both visits into one E/M code this year….
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…following payer regulations, state laws and internal compliance guidelines that your practice has in place. As long as you check those boxes, amending the medical record can paint a clearer…
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One audit type that’s always looming over medical practices involves Recovery Audit Contractors (RACs). These organizations are appointed by each MAC to uncover, confirm, and take back reimbursements Medicare made…
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…the three providers, the payer was processing claims for 80 visits a day under the doctor’s NPI. The payer audited the practice and said that although the incident-to claims were…
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…key points can help you understand what to do instead of using an ABN form for Medicare Advantage patients. Some Payers Have Specific Non-Coverage Rules In certain cases, MA payers…
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…changes to the contract, either by you or by the payer. You must know how you (and the payer) can amend the contract if needed. For instance, suppose you decide…
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…be throwing thousands of dollars out the window. That’s because payers and government auditors are reviewing documentation for nurse-visit CPT code 99211, and if they find improprieties, you could not…
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…see from them. Charges broken down by provider, payer, code: A very helpful report that every practice should have on-hand is a breakdown of charges by provider, insurer, procedure code,…
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…a message (via mail or email) to your payer contact saying you’re escalating your request to a supervisor level. You can send the email to your payer representative and cc…
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…payer the risks that come from the patient’s condition. Using the diabetes example above, you can add additional codes to show the risks the patient faces from diabetes, such as…
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…credentialing and contracting with insurers, so that person is key to helping your practice set fees, evaluate coverage criteria, and confirm claims submission processes. The practice manager is also involved…
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…referral-based, you should look into it before auditors do. Perform Self-Audits to Evaluate Your Billing Patterns Medicaid payers use data mining to evaluate whether your practice’s billing patterns are out…
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…move forward with the service, and protects your practice, so if the insurer denies it, you can bill the patient. If your form doesn’t fit Medicare’s rigid standards, the payer…
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…patients estimates of what they’ll owe you. But one slightly less-publicized part of the rule involves creating a provider directory and validating it with every payer. And if you don’t…
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…Case When you’re writing the payer, you must have a reason to support your assertion that their denial was inappropriate, and that could be based on payer directives, information from…
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…will be uniform across your patient base but won’t violate any payer rules. 2. Specify How Far in Advance Patients Must Cancel You should always make it clear to patients…
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…managed care contracts, but sometimes your payers write contracts to benefit themselves, and they might slip terms into the contract that are easy to miss. A healthcare attorney can help…
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…for you to have at least a basic understanding of how medical coding works, why payers hold it in such importance, and why it’s so tightly tied to your revenue….
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…and counseling. This type of a visit would meet 99211 requirements, but unfortunately, most payers will not reimburse it. However, as always, it depends on the payer, so don’t write…
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…add new providers, and stay on top of the 90-day revalidation requirement to avoid getting dropped from a payer contract. What Is CAQH ProView Practice Manager? This free feature of…
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…by payors issuing your practice claim denials, check out Healthcare Training Leader’s online training session, Persuade Payers to Pay Up with Successful Appeals Process. This 60-minute training session gives you…
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…or contracting with a vendor that the OIG has designated as excluded from billing Medicare and Medicaid. Without it your practice can be hit with significant enforcement actions, or worst,…
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Legally, you are not required to bill a patient’s secondary insurance plan if you are out of network. Instead, you can choose to bill the patient directly, but doing so…
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Using modifier 58 to code post-operative procedures can prevent payer denials and decreased reimbursement for services – but you must use it correctly. When coding post-op procedures, most problems occur…
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…no field_60a298f4110c3 field_5d261ad51e5f8 Payer contract negotiations Payer contract negotiations Ace Payer Contract Negotiations with Administrative Burden Calculation Payer contract negotiations are stressful. Get more money from your payers by calculating…
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…processes, check out Healthcare Training Leader’s Enrollment Training site. Just a few of the enrollment topics you’ll receive expert advice on include: Payer Delegation, Commercial Payers, Medicare PECOS (CMS Forms…
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…down with your patients to explain your no-show policy can improve compliance. Also, be sure to make it clear that payers don’t typically reimburse fees associated with late cancellations, late…
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…of practice-based patient termination letters from a variety of sources that may help you craft your own version: Highmark – example from payer American Academy of Family Physicians – example…
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…a no-show fee can increase your risk of violating payer contracting rules, and result in higher losses than the original missed appointments. It’s vital that your practice clearly understands what,…
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…payer contract will likely require you to jump through a number of hoops before you can dismiss their patients (this is true for private payers, too). Be sure you know…
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…will this person keep you from committing costly billing errors resulting in Medicaid audits and takebacks, but they’ll likely be familiar with the rules of other payers like Medicaid and…
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…calling a payer with a question about a patient’s benefits, and you get their voice mail. Here are two examples of the voicemail you might leave. One detailed and straightforward…
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…payer contracts will spell this out, it’s important that you double check. Failure to comply with payer rules can result in you being in breach of contract and dropped from…
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…20% that Medicare doesn’t cover, you must go directly to the patient versus being able to bill their secondary insurance. In many instances, the patient’s secondary payer will reimburse them…
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…designated to manage your providers’ accounts in CMS systems. That in itself can be a little tricky as you will need to comply with Medicare enrollment regulations or risk payer…
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Although last year’s pandemic put a brief pause on Recovery Audit Contractor (RAC) audits — this year they are once again in full swing. Auditors are picking up the pace…
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…sharing of provider information. So instead of having to send the same paperwork over and over again to each payer you want to enroll with, you do it once. The…
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…you’ve been dropped. For more practical, step-by-step strategies sign up for the on-demand online training series presented by contracting and credentialing experts, Olga Khabinskay, MBA, COO and Doral Jacobsen, MBA,…
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…money by the payer). Co-surgeons each receive 62.5% of the fee schedule amount, for a total of 125%. A physician assisting receives only 16% of the fee (while the lead…
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It can be frustrating dealing with payers when you don’t have a track record of success, but you don’t have to accept the payer’s terms as they present them. You…
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…and 2021. Medicaid payments: Medicaid reimbursement rates vary by state and whether the patient has managed care or fee-for-service coverage. Commercial insurance reimbursement: Private payer rates will vary. New releases:…
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…Legal Penalties for Requiring Employee Vaccinations Renegotiate Payer Contracts to Boost Payup by 12% New Sept. COVID-19 Employment Rules: Head Off Violation Penalties . . . 1633615568:44988 57370 no no…
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…Source: If the request is from a payer, you first should check your contract. You may be contractually limited based on your negotiated rate with the health plan. For instance,…
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…,” she’ll walk you through the EXACT steps of the provider relief funding application process and reporting requirements. More Online Training Resources . Renegotiate Payer Contracts to Boost Payup by…
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…careful, you could be distracted by payers’ sneaky tactics: Renegotiating Payer Contracts. Payers often shift money around, so it seems like you’re getting a rate boost in one area, when…
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You’ve been anticipating the CPT 2021 E/M coding changes and holding your breath on whether your payers will follow suit. Now with the 2021 proposed Medicare Physician Fee Schedule you…
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…longer terminal, but want to continue with hospice. Check Patient Coverage for Secondary Payer If a patient has secondary coverage, that payer may pay for services that Medicare doesn’t cover….
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…clinician provides a service “incident-to” a supervising provider, the supervising provider should sign the record. Follow Payer Rules It’s a familiar refrain, but all payers are not the same. Check…
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…referring patients. Insurance Change: If you are leaving a particular payer or insurance network, it might make more sense for your patient to find an in-network provider. Consider extending your…
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…more appropriate. Do not use modifier 59 to prevent services from being bundled or bypass payer edits. And remember: When using modifier 59, always append it to the service that…
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…can protect your employees from contracting COVID-19 such as installing sneeze guards at the front desk and check out area. Covid-19 Resources For Your Practice . SBA PPP Rule Update:…
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…to slow the spread of COVID-19, notes the CDC. Offering telemedicine visits allows patients to keep their routine visits without exposing themselves or your practice and staff. Relaxed payer policies…
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…Requirements Improve Provider Credentialing/Enrollment Results, Monitoring Tool Key Master Payer Delegation to Speed Enrollment and Payments . . . 1639686902:55179 57370 185647 no yes 80113 field_5d261ad51e5f8 PECOS surrogacy PECOS surrogacy…
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CMS and private payers have recently implemented a variety of prior-authorization, copay and cost-sharing billing waivers for the COVID-19-related services you supply to your patients. Many of the services included…
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…and some private payers mandate using HCPCS level II supply codes over CPT codes. But there are third party payers that require you report CPT codes to receive reimbursement for…
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…Kim Garner Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, on April 8th, and will be covering private payer telemedicine reimbursement Take Advantage of Our Best-selling Telehealth Resources CMS April Telehealth…
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…you call, if you don’t get similar allowances, be sure to reference what these Alabama major payers are doing – and see if your payer allows the same. Originating Site…
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…public health authority, to a foreign government agency that is acting in collaboration with the public health authority. At-risk Persons: To persons at risk of contracting or spreading a disease…
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…insurer is. Some payers require prior authorizations for 90837. If you don’t have one, the claim will be rejected and you’re patient won’t be happy. If a payer requires a…
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…services) or with private payer patients, but you may choose to do so as a courtesy. When you know services are not covered by Medicare, even though you aren’t required…
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…Online Reviews of Your Practice to Win More Patients $277.00 – $917.00 Price range: $277.00 through $917.00 Select options Head Off HIPAA Front Desk Nightmares $247.00 Select options Negotiate Payer…
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…payer contacts and federal laws. Your payer contracts require you to collect patient cost-sharing amounts. Not doing so can violate your contracts and potentially federal fraud and abuse laws. Further,…
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…extend professional courtesy in the form of waiving copays, do not also submit a claim to the payer. Waiving a copay while receiving reimbursement from the payer could be interpreted…
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…pay the lesser of your billed or contracted charge. So if you’re billing patients at a lower rate than you’ve contracted with your payer, the payer can choose to pay…
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…Know Payer Policy and Track It Policies are specific to each payer, and most payers post coverage related policies online. You should know and keep track of these policies, track…
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…ABN for services that are not part of the Medicare program (statutorily excluded services) or with private payer patients, but you may choose to do so as a courtesy. When…
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…payer — selection process in the winter/spring of 2020 and conduct onboarding for selected organizations between July and December 2020. 2. The Primary Care First model consists of two tracks…
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…1699559904:62229 57370 no yes field_5d261ad51e5f8 third-party payer appeals third-party payer appeals Third-Party Payer Appeals — How to Fight Back to Boost Reimbursements Third-party payer appeals are worth the effort but…
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…to two new Medicare Part B watch items. In 2020, tCMS and private payers will begin review of: urine drug testing services payments for speech-language pathology Good news: You’ve still…
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Getting reimbursed for preventive well woman exam claims is tricky – not all third-party payers reimburse for these services and the coverage rules vary for the payers that do. You…
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…best way to protect your payments. For these answers, read on. Will X Modifiers Instead of Modifier 59 Avoid Anthem Scrutiny? While X modifiers were introduced in 2015, most payers…
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…is triggered. Know your payer contracts. They may have restrictions, limitations on when you can terminate patients and required notification periods Follow up via mail. Send a written notification to…
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…face staff and provider 3) meets the payer’s guidelines for code usage such as Medicare’s incident-to requirements or a private payer’s variations. These guidelines require the physician be present in…
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…challenges. You’re concerned about whether it’s worthwhile to contract with a given payer, how to handle payers that don’t use CAQH, and knowing if your contracted rates are competitive. Plus,…
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For years, deductibles were so low. Payers paid most of the patient responsibility on claim submission. Those days are obviously gone putting the onus on your practice’s medical collections to…
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…payers (Medicare, Medicaid, and private payers) or seek admitting privileges at a hospital. Provider credentialing goes a step further. Credentialing is the process of obtaining, verifying, and assessing a provider’s…
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…yes payer contracting payer contracting Learn Our 11 Tricks on How to Negotiate a Payer Contract Read our blog to understand valuable payer contracting negotiation tips in order to combat…
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…payer policy. Use it when: You’ve issued a mandatory ABN and the patient has chosen option 1. GX: Notice of liability issued, voluntary under payer policy. Use it when: You’ve…
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Closed Payer Networks
Let’s begin with answering the question “What is are closed payer networks?” Closed Payer Networks Defined Closed payer networks are a payer network that currently have participating (par) providers, like…
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Payer contract negotiations don’t have to be painful. Consider these action items to help keep you focused, avoid payer pressures, and prioritize your organizational goals to ensure the right outcomes…
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…about each process below. Contracting: Complete a new provider contract with Health Net Federal Services. EDI: No action required. Per PGBA, Payer ID and EDI agreements will remain in place…
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If you report bilateral procedures — and most practices do — how you tell your payers that you performed the same services on both sides of the body depends greatly…
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What do you do when an insurance payer denies a claim for NCCI edits, but it is contrary to the NCCI edits found on CMS’s website? Whose edit guidelines take…
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…of the program. Under the Advanced Alternative Payment Model (APMs): Other Payer Advanced APMs — CMS is looking for ideas regarding the overall design of Other Payer Advanced APMs by…
Learn More…was code in the correct family and that was good enough. The problem is, that during the past year, Medicare payers didn’t give you much feedback when your coding wasn’t…
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To get your claims reimbursed, payers demand that you be as specific as possible with your ICD-10-CM code assignment. Often this means you must identify laterality and accurately adjust your…
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…your claim payments but also to elevate your negotiation game to new heights. As a dedicated practice manager, you know the challenges of navigating the complex terrain of payer contracts…
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…telemedicine services, the majority of states now have laws requiring private payers to also pay for them. REGISTER TODAY CPT Code 99211: Get $15 Per Patient on Nonphysician Work On-Demand…
Learn More…May Be Appropriate Appeals are generally appropriate when the practice believes the payer’s decision was incorrect. Examples include: Medical Necessity Denials: The payer determines the service was not medically necessary,…
Learn More…make is: “We’ve always done it this way.” Healthcare changes too quickly. Every year brings: CPT® changes ICD-10-CM updates New payer policies Documentation expectations Audit focus areas Even experienced providers…
Learn More…based on the population being served rather than assumptions about which payers are important. Review Your Payer Mix One of the best places to start is with your payer mix…
Learn More…A/R often indicate problems Consistent improvement suggests a healthy revenue cycle Increasing Days in A/R may signal: Billing delays Claim denials Follow-up deficiencies Payer payment issues This metric often serves…
Learn More…Monitor payer processing times. Review aging reports weekly. Track accounts receivable by payer. Follow up on outstanding claims. Analyze denial trends monthly. Train billing staff on payer updates. Audit documentation…
Learn More…a payer, Medicare contractor, or government agency, what should we expect, and what steps should we take immediately to protect the practice?” field_tl_medical_question Few things create more anxiety in a…
Learn More…hours discussing procedures while giving very little attention to diagnosis coding. Remember: The procedure tells the payer what you did. The diagnosis tells the payer why you did it. Without…
Learn More…(formerly CAQH), Medicare enrollment, payer contracting, revenue cycle management, and practice operations. When your team understands enrollment requirements and payer participation rules, you can reduce delays, improve planning, and help…
Learn More…recognize that protecting revenue is everyone’s responsibility. Real Practice Example A growing cardiology practice believed declining reimbursement was primarily caused by payer fee schedule changes. After reviewing its revenue cycle,…
Learn More…The payer’s electronic claim-editing system Practice management software Front-end payer edits A clearinghouse may review claims for common errors before sending them to the insurance company. When it identifies a…
Learn More…was discovered. A mistake is treating compliance issues as one-time events. A denial is not just a denial. A payer request is not just a payer request. An employee complaint…
Learn More…provided—and your documentation backs it up—you give the payer the information it needs to process the claim correctly. When the coding or documentation falls short, reimbursement, compliance, and even patient…
Learn More…establish communication channels. Review Existing Payer Contracts One of the most valuable resources during enrollment is existing payer agreements. Reviewing payer contracts can help you identify: Effective dates Participating status…
Learn More…how does claim submission timing affect cash flow?” field_tl_medical_question Every day a completed claim sits in a queue is another day before payment can begin moving through the payer’s system….
Learn More…them to payers, monitor claim status, post payments, resolve denials, and collect patient balances. Coding determines what services are reported, while billing focuses on how those services are reimbursed. Coding…
Learn More…information Entering data into payer portals Uploading supporting documents Completing Medicare and payer registration requirements Responding to follow-up requests Many organizations now require enrollment through online portals rather than traditional…
Learn More…spend significant time worrying about payer audits, HIPAA compliance, and reimbursement challenges. However, one employee complaint can quickly become a costly legal issue. Most employment lawsuits don’t start because an…
Learn More…Invalid subscriber information Wrong payer Many of these errors originate at patient registration. Filing Deadlines Were Missed Every payer has claim filing limits. Some allow 90 days. Others allow 180…
Learn More…and E/M documentation directly affected their providers. The practice conducted focused chart reviews and provider education sessions based on those topics. Months later, when a payer review occurred involving one…
Learn More…the payer believes the documentation does not support the level of service billed. This can happen because of incomplete medical decision making, insufficient documentation, payer review policies, automated claim review…
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