Contracting and Credentialing: A Complex Obstacle to Navigate

The terms contracting and credentialing are often used interchangeably, but the processes involved in each, while interdependent, are very different and have different outcomes. Contracting, in brief, is the process of creating a formal legal agreement between the payer (insurance company) and the provider (facility, physician, and/or physician extender). The contract outlines expectations and requirements of all parties. The effective date of the agreement, the reimbursement/fee schedule, place of service, termination clauses, services allowed and disallowed, etc. are all included in a typical contract. Credentialing with payers is the process …
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Taking Pictures, Dog Paddling, and Apple Picking: A Metaphorical Approach to Healthy Revenue Cycle Management Metrics

You have seen all the articles about benchmarking and standard revenue cycle management metrics. The repetition of these basic articles is nauseating. This is not one of those articles. To illustrate that, let’s start by asking, what do photography, dog paddling, and apple picking have to do with your urgent care billing? Photography Standard RCM metrics are like the settings on your digital camera. Most people set the camera to Program mode (or “P” for program) and the camera figures everything out for a good picture. Sometimes this works great …
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Ringing in 2020 with CPT Changes

It’s that time of year again. The American Medical Association has implemented the 2020 Current Procedural Terminology (CPT) code set. This year we have 394 changes: 248 additions, 71 deletions, and 75 revisions. All changes took effect on January 1. While the impact to urgent care is minor, several items bear highlighting Health Behavior Assessment and Intervention The codes in the Health Behavior Assessment and Intervention section are used to report services provided to improve a patient’s health and wellbeing utilizing psychological and/or psychosocial interventions. Services focus on the assessment …
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Already Looking Forward to 2021—and (Hopefully) Smoother Sailing with E/M Coding

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) confirmed with the final rule for 2020 that they have accepted all of the American Medical Associations (AMA) recommendations for coding of office and outpatient evaluation and management (E/M) services starting in 2021. This will offer some documentation relief for providers who have been held to dated 1995 and 1997 guidelines that were written before the use of electronic medical records. However, these guidelines should still be used for any code sets that require them outside of CPTs …
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Three Tips to Optimizing Patient Collections

Over the last decade, perhaps the most staggering shift in consumer-based healthcare has been the increase in patient responsibility. Due to the rise in high-deductible health plans (HDHPs), providers are now faced with the challenge of collecting an average of 35% of their revenue from patients, without a downward swing in the insured population. Consider the following: In 2018, 85% of covered workers had a deductible, up from 59% in 2008. The average deductible in 2018 was $1,573, up 114% from $735 in 2008. Since 2013, the burden on patients …
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