Payers Category

The fact that reimbursement rates decline while the cost of running a practice goes up is hardly a news flash. Relatively minor details in reimbursement contracts that can ultimately add up to big bucks should not go unnoticed amid all the macrodata, however, according to a recent post on Doctor Discourse. Many changes that may seem to be random moves that your staff just has to get used to may also bring new opportunities to improve your bottom line, according to the article—provided that you know what to look for.Read More
Due to its oversight by the federal government, TRICARE is challenged with limitations that don’t apply to most insurers—one being that they’re not able to offer some of the economic incentives commonly used to push patients to lower-cost care settings. At the same time, the military insurer is held to the same (or higher) standard for keeping costs under control. One strategy its administrators have come up with is a familiar one: Get patients to visit an urgent care centers instead of the emergency room unless they have a trulyRead More
Ready or Not, Here Come the New Medicare Cards

Posted On April 3, 2018By Brandon NapolitanoIn News, Payers

Ready or Not, Here Come the New Medicare Cards

It’s going to take a year for the whole batch to be in place, but your front desk staff will start seeing new Medicare cards this month. As we told you when the Centers for Medicare and Medicaid Services first announced its plans, every Medicare member will be issued a unique ID number to replace their Social Security number on the cards to better protect all manner of personal information tied to the SSN. Patients’ Medicare benefits are not changing; for a patient in a Medicare Advantage Plan (eg, anRead More
UnitedHealthcare (UHC) just launched a new protocol for evaluating emergency room claims that it says will encourage accurate coding by providers and ultimately bring down healthcare costs. Some hospitals view it as just another way to deny claims, however—and one that could actually end up costing patients more money, at that. Under the policy that took effect on March 1, UHC reviews and maintains the right to adjust or deny claims for ED visits coded at Level 4 or Level 5 for patients covered through United’s commercial and Medicare AdvantageRead More

Posted On February 13, 2018By Stuart WilliamsIn News, Payers

Anthem ED Policy is Starting to Rankle Patients

When Anthem announced some months ago it would not cover bills for “unnecessary” (in their retrospective view) trips to the emergency room in some states, we noted objections from physician groups. Now that the policy is in place and claims for 2018 have started to be filed, we’re seeing media reports on angry patients who are getting stuck with bills they presumed would be covered. Consumer Reports, for one, recounts the case of a patient who went to the ED because she thought she could be having a stroke. HerRead More
Physicians and patients alike have been vocal in their disapproval of Anthem’s policy of denying claims for emergency room visits that are ultimately declared nonemergent—the main criticisms being that it forces patients to self-diagnosis to some extent and that it ultimately may discourage patients from getting emergency care when they really do need it. Now the Indianapolis Recorder newspaper charges the policy is going to have the greatest negative impact on low-income patients, based on the presumption that urgent care centers tend to be more plentiful in higher-income communities. Anthem’sRead More
It was a long time coming, but as of January 1 patients covered by Tricare Prime can now visit any in-network urgent care center they want without a referral. The pilot program Congress instituted in May 2016 has become policy, doing away with restrictions that limited urgent care visits to two per year without receiving a referral. Point-of-service charges no longer apply, either. Tricare notes that the referral policy could be reinstated for 2019, and that the new policy does not apply to active-duty troops. In addition to those personnel,Read More

Posted On November 14, 2017By Stuart WilliamsIn Payers

North Carolina Blues Dial Up Telehealth Offerings

Blue Cross and Blue Shield of North Carolina is collaborating with MDLive to put more patients in touch with providers using remote hookups via an MDLive app, with an average wait time of less than 10 minutes. The insurer says it recognizes “the potential of telehealth to help providers deliver their services in a more cost-efficient setting…and facilitate value-driven care for patients.” That level of access is especially important in areas where ill patients would have to travel excessive distances to see a provider in person. Members with health plans withRead More

Posted On October 25, 2017By Stuart WilliamsIn Payers

An Update on MIPS Readiness

If you read this newsletter and JUCM, you know the Merit-based Incentive Payment Systems (MIPS) offers a few options in an attempt to encourage participation and allow providers, essentially, to customize their participation to suit their practice. That includes when they start participating, within some limits. And if you read any news sources at all, you know there are more than a few wrinkles in the rollout. With that in mind, here are a few highlights that may be most applicable to the urgent care clinician and operators: Both 90-dayRead More
UnitedHealthcare Commercial in New Jersey and UnitedHealthcare Oxford of New Jersey will stop reimbursement of HCPC code S9083 as of January 1, 2018, according to a letter sent to providers. Instead, the plans are advising providers to “only report the evaluation and management and/or procedure code(s) that specifically describe the service(s) performed.”  S9083, they say, is “informational” and relates to a type of reimbursement rather than a specific service. Charges billed for S9083 will be denied once the policy takes effect. They will continue to reimburse providers for all servicesRead More