Insurance news
Out of Network? Don't Expect EOBs
Friday, January 30, 2015 09:22 PM

Julie Lenhardt, Sr. Director, Insurance Advocacy

ACA has recently received a number of inquiries regarding out of network providers who are not receiving an explanation of benefits (EOBs) or a remittance advice (RA) for patients covered by plans in which the provider is out-of-network.  While such occurrences are, at this point, fairly unusual--not to mention inconvenient--for the provider, ACA wants to make doctors aware that this may become more common as payers look for ways to cut expenses in the evolving healthcare landscape.  Although it may seem as if payers are violating state regulations regarding prompt payment, that may not be the case.

The reality is that when a doctor is out-of-network, the payer has no obligation to the doctor; its only contractual obligation is to the patient.  Therefore, the patient may be receiving not only the EOBs, but also the reimbursement check for services rendered.  Unless a state has stringent statutes regarding payers honoring valid assignment of benefits, the payer is not required to notify out-of-network providers about claims status.  However, especially for those plans governed by ERISA, the plan is required to notify the patient.

Dual Coding - Friend or Foe?
Friday, January 30, 2015 09:19 PM

Jill Foote, Insurance Quality Analyst III

Many providers are under the impression that two or three months is sufficient time to prepare for the transition to ICD-10.  Thankfully, we have many other countries' experiences to draw from and know that a few months is not near the average time for implementation.  In this article, we cover the concept of dual coding, which refers to coding the same record in both ICD-9 and 10 for training and testing purposes.

Dual coding can be especially helpful when vendors begin testing their systems for ICD-10 transactions. This will require you to work closely with vendors and payers early in the implementation process. What can you do to get ready? Listed below are a few simple steps:

Two Fee, or Not Two Fee. That is the Question.
Friday, January 30, 2015 09:13 PM

By: Dr. Ray Foxworth

I spend a great deal of time connecting to colleagues at state association events across the country. But when I'm home, I like to get out and enjoy the fairs, festivals and events of my community. I'm amazed, and sometimes even amused, at the wide variety of things being offered at these events

Almost every booth at every festival brings a smile to my face-except the booths run by many chiropractors.  I see DCs offering free initial consultations. One booth said, "Come in for first exam and treatment and the rest of your family gets a $10 initial visit!" I see DCs offering coupons discounting services by as much as fifty-percent and more. I see DCs selling raffle tickets, with the grand prize being one of their services.

Great intentions, but poor execution. I am pretty sure none of these docs thought they were doing anything wrong. But every one of the examples above represents inducement or a dual fee schedule. Every one of those examples could be considered illegal in many states or at least raise the eyebrows of those in the auditing/recoupment business – formerly known as insurance companies.  If you're doing anything like it, or even close to it, please realize it is increasing YOUR risk of an audit.

2015 PQRS Resources, Payment Adjustments & the New Fee Schedule Format
Thursday, January 15, 2015 12:42 PM
Beginning January 1, 2015 and beyond the Centers for Medicare and Medicaid Services (CMS) is required to apply negative payment adjustments to the fee schedule amounts for those providers that have not successfully/satisfactorily participated in Medicare's Physician Quality Reporting System (PQRS). Doctors of chiropractic can avoid the 2 percent payment deduction to their 2017 Medicare reimbursement by successfully and satisfactorily reporting PQRS measures for Pain Assessment and Follow-Up (Measure #131) and Functional Outcome Assessment (Measure #182) during the 2015 reporting period (Jan. 1 - Dec. 31, 2015).
Payers May Require DCs to Append New Subset Modifiers
Thursday, January 15, 2015 12:32 PM
On December 17th, ACA notified members concerning the new subset of HCPCS modifiers for modifier 59 that were proposed by CMS in August, 2014.
ACA has continued to monitor whether these modifiers will be required by commercial payers, and both United Healthcare and Anthem BCBS have released information as follows:
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