Category: Billing

No Surprises Act

On January 1st, 2022, the No Surprises Act went into effect and it provides federal protections for patients from surprise medical bills.

On January 1st, 2022, the No Surprises Act went into effect and it provides federal protections for patients from surprise medical bills!  

For those that don’t remember, surprise medical bills can happen when someone receives a bill for care they thought should be covered by their insurance.

Very frequently this happens when patients seek emergency care for things like a heart attack or stroke, only to find out later that the emergency care provided was out-out-of-network. You have no way to know this ahead of time and the last thing you should be worried about in an emergency situation is the cost of your care.

In non-emergency situations you may have done your due diligence and sought care at an in-network hospital, only to receive a surprise bill months (can be more than a year) later because the doctor or other providers associated with your care may not work for the hospital and do not take your insurance.

Beginning this month, consumers with group or individual health plans are protected from receiving surprise medical bills for most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance providers.

Specifically, this law will:

  • Ban surprise bills for most emergency services even if you get them out-of-network and without prior authorization.
  • Ban out-of-network cost-sharing for most emergency and some non-emergency services.
  • Ban out-of-network charges for certain services like anesthesiology or radiology furnished by out-of-network providers as part of a patients’ visit to an in-network facility.
  • Require that health care providers and facilities give you an easy-to-understand notice explaining your new protections and who to contact if you have concerns.
  • Require health care providers to seek patient consent to waive surprise medical billing protections.

For a more detailed information about the new law, we encourage you to refer to CMS resources about the No Surprises Act.

1-Minute Pro Tip: How to Handle Claim Denials from Private Insurance Companies

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.


A denial of coverage because a PA performed the service is usually phrased as “service only covered when provided by an M.D. or D.O.” or “physician assistants not considered authorized providers under the plan.” In some cases, first assisting at surgery claims are denied for incorrect use of modifier codes (Do not assume that all companies use the same code; some use -AS, some use -80, -81, or -82.) and in other cases, those claims are denied because of the use of a restricted code or for performing a surgery not necessarily requiring a first assistant.


You may need to contact the insurance company to find out what modifier should have been used and, in some cases, you may need documentation that a first assistant was medically necessary for the surgery. Insurance companies strive to (1) retain their subscribers, (2) maintain or increase their market share, and (3) keep a positive corporate image. If the insurance company made the coverage decision and you believe that the coverage decision was unfair, enlist the help of the patient and, if applicable, the business that pays the insurance plan’s premium. Their dissatisfaction is

Sample Letter: Enlisting Patients Assistance for Claims Payment

Enlisting patient assistance in health insurance claims payment issues.

Date

_____________
_____________
_____________
_____________

RE: Outstanding Health Insurance Payment  

Dear Patient:

I am writing you concerning an issue that has arisen between [ patient’s insurance carrier ] and our office concerning payment for the services provided to you on [ date of service ].”   We have made all reasonable attempts to collect from your insurance company and have not been successful.

PATIENT MESSAGING


[Explain the reason the plan has given for not paying you, or not paying you on time. Stick to the facts. Tell the patient you’re puzzled by the plan’s contention, and that you would appreciate their help in resolving any issues. If the plan’s policy is that the patient is ultimately responsible for the full cost of care, state that.]


We would appreciate your assistance in resolving this matter by:

  • Calling your insurance company directly and asking that the claim in question be paid immediately; and,
  • By asking your employer’s human resources staff to intervene.

Should you or your employer have any questions, please do not hesitate to contact our office at [practice contact and telephone number].

Thank you very much for your assistance and we appreciate your continued business.

Sincerely,

c: [ Name of Insurance Carrier ]

Updates to UnitedHealthcare Cost-Share Waivers

To ensure members are able to access the care they need as the COVID-19 pandemic continues, UnitedHealthcare is expanding cost share waivers for our Medicare Advantage and Individual and Group Market health plans for certain services. Here’s a high-level

The following provides healthcare providers and patients with information surrounding cost-share (copays, etc.) and applicable policies as enacted by United Healthcare (UHC).

Not ALL patients covered by UHC are implicated — please read the line of business (Medicare, type of commercial insurance, etc.) before making potentially detrimental changes in your cost-share collections.

PRIMARY CARE PROVIDERS WITH UHC PATIENTS, NEW POLICIES APPLY TO YOU

To ensure members are able to access the care they need as the COVID-19 pandemic continues, UnitedHealthcare is expanding cost-share waivers for our Medicare Advantage and Individual and Group Market health plans for certain services. Here’s a high-level summary of the changes.

New! Medicare Advantage Primary Care
Care Oct. 1, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost share for Medicare

New! Medicare Advantage Primary Care
From Oct. 1, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost share for Medicare Advantage plan members for primary care professional services. This applies to in-network and covered out-of-network COVID-19 and non-COVID-19 visits, whether they are conducted in-office or via telehealth.

Telehealth Originating Site Requirements (no changes since 9/28/20)

Telehealth Originating Site Requirements (no changes since 9/28/20)

The updates to originating site requirements that we announced on Sept. 28, 2020 have not changed.

  • Individual and fully insured Group Market health plans:
    • For Individual and fully insured Group Market health plans, there are changes related to COVID-19 and non-COVID-19 telehealth visits, as well as for in- and out-of-network providers. You’ll also find state-specific rules, regulations and emergency periods on the State Provision Exception page. These may vary from federal regulations. If no state-specific exceptions apply, UnitedHealthcare guidelines will apply.
      • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020.* This means health care professionals can temporarily provide telehealth services by a live interactive audio-video or audio-only communications system for members at home or another location. For more details on telehealth billing guidance and provider type eligibility, visit UHCprovider.com/covid19.
      • COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ends Oct. 22, 2020. As of Oct. 23, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.*
      • Non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ended July 24, 2020. As of July 25, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.

Medicare Advantage:

  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020. Any originating site requirements that apply under Original Medicare are temporarily waived, so that telehealth services provided through live interactive audio-video can be billed for members at home or another location.
  • COVID-19 and non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access is extended through the national public health emergency period, currently scheduled to end Oct. 22, 2020.*
Medicare Advantage COVID-19 Treatment

Cost share waivers (copay, coinsurance and deductible) for COVID-19 testing and testing-related visits are extended through Dec. 31, 2020 for our Medicare Advantage health plans. This applies to in-network and covered out-of-network COVID-19 treatment.

COVID-19 Treatment

Individual and Group Market health plans:

Cost share waivers (copay, coinsurance and deductible) for in-network COVID-19 treatment are extended through Dec. 31, 2020. Out-of-network cost share waivers will end Oct. 22, 2020. Implementation for self-funded customers may vary.

Medicare Advantage:

Cost share waivers (copay, coinsurance and deductible) for COVID-19 treatment are extended through Dec. 31, 2020. This applies to in-network and covered out-of-network COVID-19 treatment.

COVID-19 and non-COVID-19 out-of-network telehealth visits:
  • Individual and fully insured Group Market health plans: For Individual and fully insured Group Market health plans, there are changes related to COVID-19 and non-COVID-19 telehealth visits, as well as for in- and out-of-network providers. You’ll also find state-specific rules, regulations and emergency periods on the State Provision Exception page. These may vary from federal regulations. If no state-specific exceptions apply, UnitedHealthcare guidelines will apply.
  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020.* This means health care professionals can temporarily provide telehealth services by a live interactive audio-video or audio-only communications system for members at home or another location. For more details on telehealth billing guidance and provider type eligibility, visit UHCprovider.com/covid19.
  • COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ends Oct. 22, 2020. As of Oct. 23, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.*
  • Non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ended July 24, 2020. As of July 25, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.

Medicare Advantage:

  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020. Any originating site requirements that apply under Original Medicare are temporarily waived, so that telehealth services provided through live interactive audio-video can be billed for members at home or another location.
  • COVID-19 and non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access is extended through the national public health emergency period, currently scheduled to end Oct. 22, 2020.*

Digital Therapeutics and Healthcare Reimbursement

Many digital therapeutics (DTx) providers are working to obtain reimbursement from U.S. payers. The following post discusses stategy for reaching patients and partnerships. A reputable DTx company will have a strategy for reaching patients considering whether the therapeutic is curative or designed for chronic care.

  • Digital therapeutics (DTx) represent a novel approach to delivering improved clinical outcomes, but the unstructured nature of today’s DTx access process has presented a major hurdle to broader uptake
  • Payers are still at very different stages in their acceptance of DTx, and in contrast with traditional pharmaceuticals, buy-in from senior leadership will be an essential part of the top-down decision-making process for DTx prioritization
  • Pharmacy benefit managers (PBMs) have taken a leadership role in facilitating a pathway for digital therapeutics adoption, and they are likely to remain the optimal entry point for DTx coverage and reimbursement in the near term
  • Employer groups are likely to be early advocates for the benefits of DTx after running individual pilot programs, whereas managed care organizations (MCOs) may be less receptive to covering DTx until a national body of real-world evidence becomes available
  • Ultimately, payers still have limited willingness to pay for DTx that lack clear impact on plan expenditures, and they will expect to see risk-sharing contracts on the table that can address these uncertainties

PAYER REIMBURSEMENT

More developed DTx companies are coming to discover that payer acceptance and reimbursement is key to market viability and that preparations to engage payer support need to be made in the development stage. Typically, companies partner with pharma companies to leverage traditional insurance reimbursement and distribution pathways, as in the case of Pear Therapeutics benefiting from its partnership with Sandoz. However, are seeking alternative payer reimbursement pathways, looking instead to pharmacy benefit management plans or distributing directly to patients through employers as additional benefit programs.

PHYSICIAN ADOPTION
As the oldest of the DTx have begun to mature, physician adoption is the final hurdle to consumer adoption. There are three major approaches to gaining physician adoption. Pear Therapeutics is using the pharmaceutical model, leveraging pharmaceutical distribution partnerships to make physicians aware of and willing to prescribe the product. Better Therapeutics, which develops a product for insomnia, is partnering with a pharmacy benefit plan that specifically offers a digital dispensary – effectively curating benefit-covered products in a single platform that physicians can use when making therapeutic recommendations. Kaia Health is taking a less traditional approach – the company has been targeting physicians as part of a marketing campaign, but the app is on the App Store and offers three subscription packages for patients.

Physical Therapy Referrals: Not Needed

Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.

Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.

CAN I RECEIVE PHYSICAL THERAPY SERVICES WITHOUT A PHYSICIAN’S REFERRAL?

Consumers are not required to have a referral or diagnosis in order to receive physical therapist services in the State of California. Physical therapist services may be obtained without a physician’s referral if you are a cash carrying patient, receiving treatment for up to 45 calendar days/12 visits, receiving health and wellness services, or if you are a UnitedHealthCare or Medicare beneficiary.

Please note: some health insurance companies require a referral in order for your provider to be paid. Please confirm your benefit requirements by reviewing your coverage documents or calling member services of your respective insurance company. The contact number to your insurance company is listed on the back of your health insurance identification card.

The California Physical Therapy Practice Act requires all licensed physical therapists to disclose (in writing) the following information to all consumers receiving physical therapist treatment without a physician or surgeon referral or diagnosis:

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Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits whichever occurs first.


Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

ADDITIONAL RESOURCES

Noridian Healthcare Solutions is the current Medicare Administrative Contractor for all healthcare services provided in California
Centers for Medicare and Medicaid Services
Health Insurance and Physical Therapy (For consumers)
Consumer Guide to Health Insurance

E&M Coding Advice: Simplified

E&M Coding Advice
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedu

Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.

 

Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice. 

 

Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.

 

  • Do not consider reporting the highest two codes of any code family:

  • When fewer than three distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter. 

  • Do not consider reporting the highest codes of any code family:

  • When fewer than four distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter. 
  •  

 

This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.

 

E&M Coding Advice: Simplified

E&M Coding Advice
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedu

Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.

The Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice.

Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.

  • Do not consider reporting the highest two codes of any code family:

  • When fewer than three distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter. 

  • Do not consider reporting the highest codes of any code family:

  • When fewer than four distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter. 

This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.

Don’t Lose Revenue With an Outdated Fee Schedule

If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.

If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.

Remember, insurers typically will pay you either their allowable or your fee – whichever is lower. By charging less than the allowable, you are not getting the maximum reimbursement you are entitled to receive. If you are receiving 100 percent of your billed charge from a managed care plan, this could indicate your fee is set too low.

Many commercial plans base their fees on Medicare reimbursement, making it easier for you to evaluate their reimbursement patterns. As Medicare publishes its new fee schedule each year, you have an opportunity to compare your own fees against the new rates. At the same time, you can make revenue projections for the coming year and assess the value of your managed care contracts to your practice.

Sample Letter (SB 418): Paper Claim in Process Over 45 Days (TEXAS MARKET)

Sample Letter (SB 418): Paper Claim in Process over 45 days

Dear Payer: Please be advised that this letter is to request final resolution of the claim/services in question. … We are aware that the Texas Prompt Payment law (28 TAC §§21.2801 – 21.2824) p

TO: [PAYER]

____________________

____________________

____________________

____________________

RE:  Request for Claim Resolution

Patient: _______________________

Member ID: ____________________

Insured: _______________________

Date of Service: _________________

Amount: _______________________

Dear Payer:

Please be advised that this letter is to request final resolution of the claim/services in question.

It is believed that your organization has had the paper-submitted clean claim(s) in question pending and in your possession for 45 or more calendar days. All data elements required by Texas Law were present on the claim(s) when submitted.

We believe that failure to release payment may be a violation of Texas law.

We are aware that the Texas Prompt Payment law (28 TAC §§21.2801 – 21.2824) prohibits insurers from unnecessarily delaying claims processing. Payers have 45 days to (1) pay the total amount of a clean claim in accordance with its provider contract, (2) pay the undisputed portion and notify the provider in writing why the rest won’t be paid or (3) notify the provider in writing why the claims will not be paid.

If a carrier is unable to pay or deny a paper claim within 45 days, in whole or in part, and audits the claim to determine whether the claim is payable, the payer must notify the physician that the claim is being audited and pay 100% of the contracted rate.

Payers that violate these requirements are liable to a provider a graduated penalty in addition to the contracted rate and may be subject to an administrative penalty by the Texas Department of Insurance.

Since the paper claim(s) in question were received by your company over 45 days ago, we are requesting the following at this time:

  1. For claims paid up to 45 days late, the contracted rate plus the lesser of 50% of the difference between the billed charges and the contracted rate or $100,000; or,
  2. For claims paid 46-90 days late, the contracted rate plus the lesser of 100% of the difference between the billed charges and the contracted rate or $200,000; or,
  3. For claims paid more than 90 days late, the contracted rate plus the lesser of 100% of the difference between the billed charges and the contracted rate or $200,000, plus 18% annual interest on the penalty amount.

Thank you for your prompt attention to this matter. Should you have any questions, please contact our office at ____________________________.

Sincerely,

[PROVIDER]