Medicare/Medicaid Archive

Real Time Claim Adjudication – The Next Generation of Claims Submission

As a result of the rising cost of healthcare, today’s patient pays more for their healthcare which puts an increased burden on physicians to seek collections from patients.  This component of a patient’s bill may be due to copayments, coinsurance, deductibles, or non-covered services which can be difficult to collect.  For example, with the onset

E-Prescribing Developments and Considerations – Part V

Many providers have asked for information regarding the application process for participating in E-Prescribing. In fact, there is not a formal, onetime application. However, a provider (or practice, as the case may be) will not be entitled to a bonus unless he or she consistently represents – in the context of claim submission – that

E-Prescribing Developments and Considerations – Part IV

As previously discussed, there are three main requirements for earning a Medicare E-Prescribing bonus. During the prior blog we considered the first requirement, i.e., the use of a “qualified” E-prescribing system. Today, we will address the second of the three requirements. In order to qualify for a Medicare bonus, at least 10% of a provider’s

E-Prescribing Developments and Considerations – Part III

There are three primary requirements for earning a Medicare E-Prescribing bonus. Today, we will address the first of the three requirements, which is the consistent usage of a “qualified” E-Prescribing system. A qualified E-Prescribing system is one that: 1. Generates a complete medication list; 2. Allows the prescriber to select medications, transmit prescriptions electronically using the

E-Prescribing Developments and Considerations – Part II

One of the primary reasons for the current swell in interest in E-Prescribing is Medicare’s 2009 bonus. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (“MIPPA”) (followed by the Medicare Physician Fee Schedule for calendar year 2009) creates a bonus for providers who are successful E-Prescribers during 2009. The 2009

E-Prescribing Developments and Considerations – Part I

With increasing frequency, healthcare providers are giving serious consideration to the adoption and implementation of an E-Prescribing system. Some of the most often cited reasons include the following: enhancing quality of care, increasing practice efficiency, reducing medical malpractice liability (and premiums) and qualifying for governmental and commercial payer incentives. The following is noteworthy: An E-Prescribing

Jury Awards Deaf Patient $400,000 for Doctor’s failure to Provide Interpreter

In a remarkable development, a New Jersey jury has just awarded a deaf patient $400,000 for her doctor’s failure to provide an American Sign Language (“ASL”) interpreter. According to the complaint filed by the patient, Irma Gerena, she was referred to a Jersey City-based rheumatologist in 2004. She alleged that she visited the rheumatologist for

Anthem BCBS of Indiana Climbs On Board the Pay-For-Performance Bandwagon

Medicare implemented its Physician Quality Reporting Initiative,which is also known as PQRI. Doctors who satisfied the quality of care and reporting requirements under PQRI received bonuses equal to 1.5% of their 2007 reimbursements. A very limited number of small to medium size practices have opted to participate in PQRI due to the onerous reporting requirements

Medicare to Stop Paying for Certain “Never Events”

Beginning tomorrow, Medicare will no longer provide reimbursement for certain newly added “never event.” In particular, Medicare will refuse to provide reimbursement for the following conditions: Surgical site infections following certain elective procedures Legionnaires’ disease Extreme blood sugar derangement Lung collapse (Iatrogenic pneumothorax) Delirium Ventilator-associated pneumonia Formation/movement of a blood clot (Deep vein thrombosis/Pulmonary Embolism)

After years of Litigation, E/M Denials Persist

Notwithstanding years of litigation and multi-million dollar settlements, many healthcare providers continue to experience inappropriate evaluation and management service (“E/M”) denials. Earlier today, I spoke with a provider who had a well-founded complaint regarding his denials, so I want to take a minute to quickly review the basics. E/M is a visit or consultation provided