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Surprise Billing Regulation a Gift to Payers, Blow to Providers

Healthcare industry groups representing providers are upset with the latest surprise billing regulation detailing the independent dispute resolution process. The American Medical Association (AMA) is calling the latest in a series of surprise billing regulations “an undeserved gift to the insurance industry that will reduce [healthcare] options for patients.” The statement comes as the Biden-Harris Administration seeks to button up implementation of the No Surprises Act by the end of the year. The Act prohibits surprise medical billing in most situations by making it illegal for providers to bills patients more than the in-network cost-sharing amount for care. The latest regulation seeking to implement the ban on surprise billing detailed the independent despite resolution (IDR) process by which payers and providers will settle reimbursement rates for out-of-network care that would have resulted in a surprise bill for patients. The regulation released late last week included details,

AMA Issues CPT Codes for Pediatric Doses of Pfizer COVID-19 Vaccine

To prepare for potential FDA authorization, AMA has released new CPT codes for pediatric doses of the Pfizer COVID-19 vaccine. he American Medical Association (AMA) has issued new Current Procedural Terminology (CPT) codes for pediatric doses of the Pfizer COVID-19 vaccine. In September 2021, Pfizer and BioNTech shared the results of a Phase 2/3 clinical trial in which two doses of the vaccine elicited a strong immune response in children ages 5 to 11. Following the trial, the companies submitted the data to the Food and Drug Administration (FDA). Pfizer recently announced that they have submitted a formal request to the FDA for emergency use authorization of their COVID-19 vaccine in children ages 5 to 11. In August 2021, the FDA granted full approval of the Pfizer-BioNTech vaccine for individuals 16 and older. The AMA updated the COVID-19 vaccine CPT codes to ensure preparedness if the FDA approves Pfizer’s two-dose pediatric vaccine. The early publication may help healthcare pr

Avoiding Claims Denials in Your Practice

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Why the revenue cycle is vital to exceeding patient expectations and driving financial performance July 2, 2021 Joe Polaris, MBA As physician practices look for ways to build volume and engagement, it’s critical to thoughtfully consider it all from the point of view of patients and consumers. With the COVID-19 vaccine becoming more widely adopted, the US is slowly starting to emerge from the pandemic. While some things, like in-person gatherings, are starting to go back to pre-pandemic normal, there is still a long way to go when it comes to financial recovery. This may seem especially daunting for physician practices, with gross revenue losses estimated at $67,774 per physician in 2020 . Call Today: 614.706.5206          

Why the revenue cycle is vital to exceeding patient expectations and driving financial performance

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With the COVID-19 vaccine becoming more widely adopted, the US is slowly starting to emerge from the pandemic. While some things, like in-person gatherings, are starting to go back to pre-pandemic normal, there is still a long way to go when it comes to financial recovery. This may seem especially daunting for physician practices, with gross revenue losses estimated at $67,774 per physician in 2020 .

Getting Paid Today: Challenges and opportunities for independent practices

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New legislation, as well as changes in patient expectations, present a host of challenges and opportunities for getting paid for service this year. In a recent article in Physician’s Practice, we discussed the challenges surrounding getting paid for telehealth this year and beyond . This is an essential issue for independent practices, but it’s not the only one. New legislation, as well as changes in patient expectations, present a host of challenges and opportunities for getting paid for service this year. E/M Office and Outpatient Guidelines Changes For the first time in more than two decades, the AMA has revised the guidelines for office and outpatient visit evaluation and management (E/M) codes. It’s been a long time coming—effective this year, CMS has aligned E/M coding with the changes adopted by the AMA. For many providers, this means an increase in their revenue because they will finally be compensated for time spent in activities related to patient care that were previously

Key considerations for revenue cycle teams to optimize coding and maximize revenue during COVID-19

A new code for COVID-19 discharges offers a 20% bump in the assigned MS-DRG payment from CMS. Clinicians should know that a positive test result is not required to establish a COVID-19 diagnosis for coding purposes. If a patient admitted with a respiratory diagnosis then tests positive for COVID-19, coders can link the result to the respiratory illness. With new legislation such as the Coronavirus Aid, Relief and Economic Security (CARES) Act supplying grants to help stabilize hospitals and health systems, documentation and coding become increasingly vital for providers to capture the available funding. An unprecedented off-cycle adoption of code U07.1, COVID-19 , effective with discharges on and after April 1, 2020, was announced by the Centers for Disease Control and Prevention in mid-March.  As provided in the ICD-10-CM Official Guidelines for Coding and Reporting, the coding guidance for COVID-19 has unique features that all coding professionals and clinical documentation special

4 ways to keep ahead of denials amid the pandemic

Revenue cycle leaders share approaches to keeping up with new codes and evolving payment guidelines during COVID-19. Understanding all that’s required to secure healthcare payment during a pandemic — especially for services related to COVID-19 — demanded that revenue cycle teams quickly refine denials management processes to protect their organization’s financial health. It also necessitated a spirit of patience and understanding toward payers, which faced a similar learning curve, according to Richard Madison, network vice president for St. Luke’s University Health Network in Bethlehem, Pennsylvania. “It takes two parties to get this right,” Madison said. While Madison and his peers encountered many obstacles that have complicated the task of denials management — including adapting to the needs of a remote workforce and dealing with the uncertainties surrounding payment for an unprecedented volume of telehealth services — their experiences also point to key factors in protecting reven