<strong>Tips for Payer Reviews</strong>

Tips for Payer Reviews

Monte Sandler Insurance plans are scrutinizing claims more than ever before. Common questions from our clients are: What does this mean? What should I do? Should I be worried? Generally, there are three types of payer reviews: prepayment, postpayment, and probe. The first step is to figure out what type of review it is. What you do and how you handle the review is dependent on that information. Should you be concerned? Always. Payer reviews …

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Where Do You Start When Starting Your Urgent Care?

Where Do You Start When Starting Your Urgent Care?

Heather Real There are many reasons to start your own urgent care, whether it be feeding your entrepreneurial spirit, investing in an industry that has proven to be stable and growing (even amidst multiple economic crises in the last three decades), or responding to the needs of a community. For many, the reasons include at least some of these, and more. Realizing the desire to take on this project is the first step; however, there …

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New ICD-10-CM Codes in Effect as of October 1

It’s time for the major release of ICD-10-CM that occurs on October 1 every year. For 2023, this update reflects 1,468 new codes, 251 deleted codes, 35 revised codes, and 36 codes converted to parent. Like the last few updates, Social Determinants of Health (SDOH) are front and center. SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, …

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Primed for Growth: Why It’s Time to Consider Adding Primary Care Services to Your Urgent Care Center

Primed for Growth: Why It’s Time to Consider Adding Primary Care Services to Your Urgent Care Center

Many patients don’t think about “urgent care” until the moment they need treatment. Likewise, few people think of urgent care when considering a routine check-up at the doctor’s office.  Perhaps it’s time for that to change.  The main demographic served by urgent care consists of “working age” adults, 24-54, and their families. Historically, these patients lack a primary care provider (PCP). Whereas children have a pediatrician and seniors in a Medicare plan are likely served …

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A Half Century of Urgent Care: What Today’s Startups Need to Know

The urgent care industry is in its fifth decade and still growing! The driving forces of affordability and accessibility continue to fuel this growth. Success has been propelled by the agility of urgent care operators in adjusting their business model to meet the demands of their communities. Initially, urgent care centers were a welcome supplement in communities where the emergency department was the only option for medical care apart from PCPs or specialist offices. Roughly …

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Decreasing Denials and Rejections Through Your Urgent Care Operating Model

A wise person once said, “If a claim is rejected or denied, the energy to get it paid is five times the energy if it went through as a clean claim.” Maybe it is only four times or three times the work, but the point is that we should all do everything we can to avoid rejections and denials! Unlike more complicated specialties subject to complicated coding, authorization, and other factors, in an urgent care …

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Urgent Care Billing: Best Practices Scorecard

When it comes to measuring your financial performance, metrics translate the actions of others into insight. They provide visibility into the efficacy of your overall billing process. But while they may shine a light on where you need to improve, they don’t tell you how to do it. For a better understanding of how well your clinic is optimizing the billing process, look at your everyday practices. Our revenue cycle management (RCM) experts compiled 10 …

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2021 E/M Guidelines: Your Questions Answered

It’s been 14 months since the new evaluation and management guidelines took effect. Many providers struggled to modify their documentation after 25 years with the 1995 guidelines. Urgent care practices stepped up with training programs to get through the learning curve with some new concepts. This month I’ll address some of the common questions that we receive. Do I have to meet the level in all the elements to bill a code? No, the level …

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What Else is New in 2022?

The Protecting Medicare and American Farmers from Sequester Cuts Act was signed into law on December 10, 2021. This law addresses the reduction in the 2022 Conversion Factor set by the Physician Final Rule, as reported in my December column, increasing the 2022 Conversion Factor by 3%. The new conversion factor becomes $34.61 compared to $34.89 in 2021. With the increase in Relative Value Units on most E/M codes, the impact to 2022 rates becomes …

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Refunds: How to Avoid Them

Refunds: How to Avoid Them

Refunds have always been a challenge in healthcare. Not only do they create an administrative burden but there is also the potential for compliance risk. Some common causes for refunds are: Not validating the patient’s insurance eligibility and collecting the wrong copay amount Choosing a blanket amount to collect from all patients up front regardless of whether  they have insurance (ie, over collecting at the time of service) Sending statements too early, causing duplicate payments …

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