The proposed Medicare Physician Fee Schedule (MPFS) for 2022 estimates a CY 2022 conversion factor of $33.5848 compared to 2021 at $34.8931.
CMS estimates an overall impact on radiology to be a 2 percent decrease, with interventional radiology seeing a decrease of 9 percent, nuclear medicine a 2 percent decrease and radiation oncology and radiation therapy centers a 5 percent decrease.
If the pause in the two-percent sequestration cut is allowed to expire, as planned, on December 31, 2021, these decreases will be larger, unless Congress intervenes.
Late in 2021, Congress included a 3.75 percent adjustment to the 2021 conversion factor which rolled back the payment cuts to radiologists from 10 percent to approximately 4 precent. While Congressional action is possible for 2022, that uncertainty will remain until late this year.
On July 1, HHS and other federal departments issued an Interim Final Rule (IFR) related to the No Surprises Act passed by Congress in late 2021. These provisions are to go into effect on January 1, 2022.
Billing at of out-of-network (OON) rates will be much more difficult
Most/all emergency situations, including most follow-up care must be paid at in-network rates
This includes most hospital-based providers, not just ER physicians
Non-emergency care will require substantial advance notice, including a good faith estimate of costs provided to the patient
Emergency treatment at hospital ERs and free-standing ERs will essentially be paid at in-network rates
Specifically, the IFR requires emergency services to be covered
Without prior authorization.
Regardless of whether the provider is an in-network provider or an in-network emergency facility.
Without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes.
Initial emergency care, post stabilization and potentially follow-up in-patient treatment are included in the definition of “emergency.”
Emergency treatment includes “ancillary services”; i.e. most hospital-based providers
In addition to emergency medicine, anesthesia, radiology, pathology, hospitalist, neonatology and other “ancillary services” are included in the provisions.
While the payment rules are complex, patients must pay no more than their in-network deductible and cost share
The “No Surprises Act” limits what patients pay in these scenarios to their in-network cost-sharing amount. It also applies this cost-sharing to their in-network deductible and annual out-of-pocket maximum, prohibits the patient from being balance billed for any additional amount, and removes the patient from the reimbursement dispute process between their health plan and the OON Provider.
The patient’s cost-sharing is not based on the total OON charge. Rather, it is based on a “qualifying payment amount (QPA).” The IFR defines the “qualifying payment amount” as the lesser of the billed charge or the health plan’s median contracted rate unless otherwise specified by a state’s law or by an All-Payer Model Agreement.
The IFR details how health plans must calculate the median rate for the QPA. The agencies will conduct regular audits of health plans to ensure compliance with how the QPA was calculated.
Payment must meet these criteria
An amount determined by an applicable All-Payer Model Agreement under section 1115A of the Social Security Act.
If there is no such applicable All-Payer Model Agreement, an amount determined under a specified state law.
If there is no such applicable All-Payer Model Agreement or specified state law, an amount agreed upon by the plan or issuer and the provider or facility.
If none of the three conditions above apply, an amount determined by an independent dispute resolution (IDR) entity.
The IFR leaves the IDR to be defined later.
For non-emergency situations, prepare for notices and consents
If you practice in an in-network hospital but are not in-network with a patient’s insurance, you must provide an electronic or paper notice. The notice is intended to prevent surprise bills when the patient incorrectly assumes the services will be in-network. The notice is to include charge estimates and alternative in-network providers available (if any) and a clear statement that consenting to out of network services is optional and that in-network providers may be available.
Notice and consent can only be sought for certain non-emergency services or certain post-stabilization services.
To balance bill for post-stabilization services, an OON provider or emergency facility must provide notice and get consent from the (stabilized) patient but only if these four conditions are met.
The treating provider must determine that the patient is able to travel using nonmedical transportation to an in-network provider or facility within a reasonable travel distance, taking into consideration the individual’s medical condition;
The provider/facility must satisfy notice and consent criteria (a model notice was published simultaneously with the IFR);
The participant or their authorized representative must be in a condition to provide informed, voluntary consent; and
The provider/facility must satisfy any additional state law requirements.
Why AI Technologies are a Fit for Medical Billing Companies
WARREN, NJ – July 27, 2021: AdvantEdge Healthcare Solutions (“AdvantEdge”), a leading national medical billing company with comprehensive, coding, practice management and revenue cycle management services, today released a Special Report about how Artificial Intelligence (AI) and Machine Learning (ML) are transforming the medical billing landscape.
Three highlights from the report offer an inside view about how AI and ML are impacting medical billing and how these technologies allow healthcare providers to ensure all billing – and the entire revenue cycle management process –is handled efficiently, accurately, and in a timely manner.
AI is A-OK: The tremendous amounts of information captured every day from hospital information systems, clinical platforms, and patient accounting systems leaves a large margin for error. Inconsistencies and incorrect information can be efficiently and expediently addressed by automating certain processes using artificial intelligence.
A Matter of Time: Patients should be able to interact with chatbots around the clock to resolve a variety of issues, allowing customer service representatives to handle more complex issues that cannot be more simply resolved.
Meet Machine Learning: A subset of AI, ML possesses the ability to automatically learn and build on prior knowledge – without explicit programming. ML can handle a wide range of billing discrepancies and payer behaviors that would be nearly impossible to address otherwise.
Click here to read this Special Report in its entirety.
About AdvantEdge Healthcare Solutions AdvantEdge is recognized as one of the top ten U.S. medical billing companies providing billing, certified coding and practice management services to healthcare providers nationwide. AdvantEdge collects more than $1 billion annually for physicians, hospitals, ambulatory surgery centers, behavioral health agencies and large office-based medical groups. Client-first service, robust technology, and actionable business intelligence and reporting translate into healthier practices and enable AdvantEdge’s clients to have the freedom to focus on delivering world class clinical care to their patients. To learn more about AdvantEdge, visit our website at www.ahsrcm.com. Follow us on Twitter at @DoctorBilling and on LinkedIn.
Last Thursday, the Biden administration unveiled the Interim Final Rule, indicating how the No Surprises Act will be implemented. While comments are being solicited until September 1, HHS chose to skip a Proposed Rule and go straight to an Interim Final Rule, most provisions of which will be effective January 1, 2022.
Congress approved the No Surprises Act last December in order to eliminate so-called “surprise billing.” The Rule requires billing in emergency situations to match in-network rates with no requirement for prior authorization. The rule also prohibits out-of-network charges for ancillary services, such as radiology, anesthesia, and other providers, at an in-network facility.
Restrictions on out-of-network charges also apply to non-emergency situations, such as childbirth. How these provisions will apply to specialists is of particular interest and concern, and may lead to tension between providers and patients, according to Axios. In most, if not all, cases, providers will be required to post notices related to possible out-of-network billing.
Not addressed in the rule was an arbitration process, required by legislation, for cases where in-network rates are not established. Ground ambulance billing is also not addressed because it was excluded from last year’s legislation.
To learn more, please find additional coverage on the Interim Final Rule:
Is the Labor Shortage Hurting Your Billing Today? Tomorrow?
Is your practice having trouble hiring due to the labor shortage? Is this already impacting your billing needs, or will it in the near future? Medical practices have two billing options: partnering with a medical billing company or supporting an in-house billing department—where costs are increasing every day. The right option for you depends on both effectiveness (measured by performance) and efficiency (measured by costs). Check out our most recent blog post for more. Read more
COVID-19 | 1 min read
New OSHA COVID-19 Rules for ALL Healthcare
New U.S. Labor Department COVID-19 workplace safety rules go into effect July 6. Among other requirements, they mandate that employers provide PPE, paid time off to get vaccinated and to recover from side effects and more. Read More
CMS | 2 min read
Pandemic Swells Medicaid and ACA Enrollment, a ‘High-Water Mark’
According to a recent report, Medicaid enrollment grew from 71M in February 2020 to over 80M in January 2021. In addition, ACA marketplace plans have added a million enrollees since February, now covering over 12M. Read More
Telehealth | 1 min read
Americans Want Telehealth to Stay
U.S. health industry leaders and patient advocates, notably HHS Secretary Xavier Becerra, are pushing Congress and the Biden administration to preserve the pandemic-fueled expansion of telehealth services. Read More
CMS | 1 min read
Healthcare Price Increases Slow, but Projected to Rise Next Year
While healthcare price increases have recently dropped to 2% (from 2.5%+ over the past year), a PwC report suggests that healthcare costs will increase by 6.5% in 2022 due to continued COVID-19 impacts on spending. Read More
AdvantEdge News | 1 min read
AdvantEdge Wins Bid to Provide EMS Billing Services to Carroll County, MD
Read more about our new client, Carroll County, MD, and how AdvantEdge will provide a full suite of services to standardize billing for their Fire/EMS department. Read More
In-house Medical Billing vs. Outsourced Revenue Cycle Management
Learn about the key factors in supporting an in-house medical billing department or using a medical billing company.
In the Midst of a Labor Shortage, Is Your In-house Billing Operation Still Performing?
Is your practice or department having trouble hiring billers? Have you lost staff during the COVID pandemic? If so, you aren’t alone. Many workers haven’t returned for a variety of reasons, from not having child care to generous unemployment packages to fear of getting sick, pera recent article in The New York Times. And, surprisingly to many, the labor shortage is expected to be long term, not just a short-term inconvenience!
Medical practices have two billing options: partner with a professional medical billing company or support an in-house billing department. The right option for you depends on both efficiency (measured by cost) and effectiveness (measured by performance).
Consider a practice with a four-person billing staff where one needs to be replaced due to COVID or other reasons. From a cost perspective, the four staff members typically would get two to three weeks of vacation and five to 10 sick/personal days. That means 60 to 100 days out of the year, 25 to 40 percent of workdays, where the department is operating short-staffed. A larger staff has the same issue, with slightly less impact on productivity. But in all cases, the costs for salaries, benefits, and other overheads go up every year. And, considering the labor shortage, expect them to go up faster, to higher levels than most are forecasting.
There are also overhead costs associated with in house billing. Hiring, training and supervision are obvious ones, but don’t forget benefits, bonuses, billing system, IT support, training, office space, miscellaneous costs, etc. Given the current and expected labor shortage, it’s important to factor in significant annual cost increases in nearly all of these areas. Once you assess all these personnel and overhead costs, you can compare them with a medical billing company fee. Note that most, if not all of these costs are increasing every year.
While not strictly a cost issue, some physicians find managing a billing staff takes more time and effort than they would like: especially when staff shortages or other daily challenges interfere with revenue generating clinical activities, or family time. For many practices, the current labor environment is exacerbating this concern and causing tremendous burdens on the physician(s) responsible for overseeing the billing operation’s performance.
Medical billing services typically charge a percentage of the collected reimbursements. This is a variable expense vs. the fixed cost of in-house billing. Also, these fees are usually locked-in for a three or five year period. In other words, while the costs of running an in-house operation are generally fixed and increase every year, the costs of using a billing company are variable, based on performance and can be locked in for three to five years, sheltering your practice from escalating labor and other costs.
Is it less expensive to bill in-house? Usually not, given the economies of scale of a sophisticated billing company. But each practice needs to do the math for its unique situation. Just be sure, given the current and expected labor environment, to factor in significant annual cost increases for in-house billing.
Many in-house billing operations are effective at collecting reimbursements owed. But this effectiveness is at risk without a stable, trained staff and consistent management and leadership. Where specialized skills are required, the challenge can be even greater. As the patient portion of reimbursement grows, it takes a very specialized staff to share patient compassion and, at the same time, be effective in a collection effort. This can be extremely difficult to train and manage in-house.
If you partner with a medical billing company, many of the challenges that affect a small or medium-size team are eliminated. A medical billing company should bring state of the art billing software as well as professionals with expertise in your specialty plus medical coding and billing that are up-to-date on regulations, compliance, and other industry standards.
If a practice requires specialized skills (e.g. specialty coding), a medical billing company may be much more effective (and efficient). If a practice requires the equivalent of specialized skill half of the month, they may need a full-time person on staff. Medical billing companies can share specialized resources across clients. They are also likely to have better training opportunities and better career paths for coders and billers than with most in-house billing operations, leading to greater stability and experience.
At the end of the day, a physician practice generally tries to minimize the expenses of its in-house operation, since it is a “cost center.” This means investing as little as possible in tools, training, technology and people. In contrast for a billing company, like AdvantEdge, the billing operation is its revenue center and enjoys meaningful investment in tools, training, technology and people. If interested, a great way to measure your performance against that of a medical billing company is to compare your current net collections percentage, days in A/R, and A/R greater than 120 days outstanding (the three most identifiable metrics used by the industry) to projections from a medical billing company.
As the news points out, now is a good time to assess or re-assess your staffing situation and business methodologies…as Bob Dylan said, “The times they are a’ changing.” You need to make sure you are staying current and, potentially, changing with them. To see if a medical billing service might make sense for your practice,reach out to an AdvantEdge expert today to learn more. You can also follow AdvantEdge on LinkedIn to stay current on company and medical billing industry news.
We’re proud to announce that AdvantEdge has been selected to standardize EMS billing for the Carroll County Fire/EMS Department, which is a new Department of the Carroll County Government, created in October of 2020. The Department consists of 14 fire stations, providing Basic Life Support (BLS) and Advanced Life Support (ALS) services from 15 ambulances. AdvantEdge scored the highest of nine potential medical billing companies by a Carroll County committee formed to evaluate the technical and financial capabilities of each vendor.
AdvantEdge will provide a full suite of emergency medical transport billing, collection, and financial reporting services.
“AdvantEdge has a lot of experience working with counties and local communities, and is one of the leading companies that provide billing services for ambulance and EMS in the state of Maryland,” stated David Langsam, President and CEO of AdvantEdge. “We look forward to working with Carroll County and unifying their billing services with our proprietary technology and client-first approach.”
Learn more about how we can help you with your medical billing needs by visiting AdvantEdge.com, and stay up-to-date on AdvantEdge news and trends by visiting our LinkedIn page.
As one of the most critical components of the medical billing process, medical coding cannot be overlooked when it comes to ensuring that healthcare providers collect all money due for services delivered. In this blog post, we suggest Key Questions about medical coding. A medical billing company must have stellar coding capabilities to achieve successful financial outcomes for its clients. Unfortunately, many providers fail to investigate medical coding capabilities prior to partnering with a medical billing company. Here are eight key medical coding questions to ask of your billing department, current medical billing company or billing company you are considering. What you don’t ask about coding can hurt your bottom line!
1. Are your coders certified and do they have the specific certifications associated with my specialty(ies)?It’s impossible to offer superior coding capabilities without employing the best people for the job. Coders should not only have the necessary credentials, but the credentials specific to your area(s) of practice, as well as extensive and relevant expertise, and depth of knowledge required to handle the complexities of the coding process.As an example, AdvantEdge coders have deep credentials in each of our clients’ specialties, including radiology, interventional radiology, emergency medicine, pathology, pain management, and anesthesia, among others, along with certifications and experience in subspecialties (neurological radiology, derma pathology, etc). To help clients keep up with the most current industry updates and changes, ongoing in-house training is required of all coders, including annual ICD-10 and CPT updates.
2. How quickly can you adapt to planned or sudden and unpredictable changes on the medical coding frontier? Recent history has taught us that change is inevitable and unpredictable. This was witnessed with COVID. A medical billing company must adapt to change efficiently and expediently – whether the change is planned or takes the industry by surprise. AdvantEdge was able to adapt to COVID largely because of the company’s technology foundation and the expertise of its people who were well equipped to work remotely. Due to proprietary technology and extensive protocols that were already in place, the AdvantEdge coding team responded to the new COVID landscape with relative ease. The rapid emergence of telehealth and COVID coding rules were quickly adapted with new training and updated workflows. What’s more, AdvantEdge is also prepared with transition strategies when COVID coding provisions potentially revert to pre-COVID status. As another example, when providers were given the direction earlier this year to select E/M codes based on total time spent or medical decision making (MDM), AdvantEdge was well prepared and quickly incorporated this change.
3. What is your process when dealing with coding related denials? Although denied claims are an inevitable reality, the issue is how – and if – these denials could have been avoided and are dealt with in a way that allows for the best possible financial outcomes. Coding denials should be tracked and trended to identify systemic areas of concern, either related to provider documentation, information flow from provider location(s), or issues related to coding performance within your coding department (or that of the billing company you use). Quantification and trending of these denials are the best ways to ensure you are identifying and addressing root causes to ensure problems are being resolved and do not perpetuate. AdvantEdge has a cohesive and time-tested process for handling denied claims to ensure they are addressed and handled expediently. When it comes to claim denials, fast and thorough follow-through is essential to making sure each valid claim is reimbursed for our clients. Additionally, AdvantEdge provides its clients with detailed denial reports that demonstrate how denials trend over time, to ensure positive progress and momentum, leading to improved and expedited cash realization for clients.
4. How often do you audit your practice’s (or in the case of a billing company, how often do they audit their client’s) documentation for compliance purposes? A practice doing its own billing, or its medical billing company, must ensure that they, as well as the physicians they serve, are aware of the relationship between documentation and coding in order to remain compliant. This necessitates ongoing oversight and audit of documentation. For this reason, AdvantEdge provides most clients with a formal audit at least annually, offering valuable feedback to help providers understand any issues that may arise and need to be addressed. As necessary and /or as desired by clients, AdvantEdge also provides them with education on proper coding and documentation. If AdvantEdge notices trends of coding errors or other inconsistencies, root cause analysis is completed followed by an action plan that incorporates preventative measures for moving forward, independent of the audits mentioned above.
5. What is your typical coding turnaround time (TAT)? We all know that time is money. At AdvantEdge, the majority of our clients have a 48-hour coding turnaround time. If there is a unique situation around specific claims, our team is always equipped with an action plan to handle those exceptions. When it comes to medical billing and coding, we understand that time is of the utmost importance.
6. What actions are taken if a payment comes in lower than the current fee schedule allows due to coding discrepancies? Your billers ormedical billing company must be aware of the most current contracts and fee schedules to ensure that you get the proper amount due for delivery of services. Your billing department or billing company needs to have a system in place to track payments against contractual amounts, otherwise these underpayments will not be flagged and may get inappropriately transferred to patients or written off as bad debt. While these “underpayments” may seem arbitrary, oftentimes they are coding related, and you need to ensure you have appropriate documentation to evidence the procedures performed, along with related acuity levels, to overturn such underpayments. AdvantEdge understands that many providers don’t have time to investigate annual contract and fee-schedule updates, so we keep abreast of these changes and have the systems necessary to load clients’ payer contracts into our system. This process enables us to identify underpayments as exceptions and follow up with payers to appeal and overturn such underpayments before seeking to collect from the patient or another third party…all to ensure we are collecting all money due to our clients.
7. In the case of a billing company, do clients have access via phone to live coding specialists to answer questions about complex medical coding issues that may arise? Although technology is integral to the medical coding process, some situations require human intervention. A medical billing company must have coding experts on hand to deal with unique and complex situations that require human intervention and interaction. AdvantEdge realizes the importance of giving our valued clients access to appropriate specialists who can promptly explain, address, and resolve questions that require immediate clarification.
8. Does the company utilize leading edge technology and automated workflows to assure full reimbursement? One of the keys to properly billing for your practice or becoming a leader in medical billing is a company’s ability to incorporate and utilize the latest technologies. AdvantEdge’s proprietary software allows us to quickly adapt to changes in coding regulations, along with all aspects of revenue cycle management [from beginning to end]. This enables us to deploy more human resources where they can have the biggest impact, such as managing exceptions, educating our clients, communicating with your patients, and handling complex claims and other items that may arise in the billing process.
The second blog in our three-part medical coding series will highlight the importance of technology and automated workflows. Until then, keep up to date on AdvantEdge and its medical billing initiatives by visiting our LinkedIn page.
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