KLA Healthcare Consultants

09/05/2025

🚨 Medicare Signature Rules: More Than Just a Scribble! 🖊️

When it comes to Medicare claims, your signature isn’t just a formality—it’s the key that proves services were ordered, provided, and properly documented. Miss it, and you might be waving goodbye to payment. 💸

Here’s what you need to know (and yes, CMS really spells it out):

✔️ Handwritten signatures must clearly show your approval or obligation. (Illegible chicken scratch? Use a signature log!)
✔️ Stamped signatures are not accepted—unless you have a disability and CMS has proof.
✔️ Scribes & AI are allowed for documentation—but the provider must still sign to authenticate. 🤖
✔️ Missing signatures? You can file an attestation (except for orders). Think of it as a belated “Yes, I really meant that.”
✔️ Medical students can document, but you must review and sign. No shortcuts here.
✔️ Electronic signatures are fine—just make sure the system prevents alteration and meets legal safeguards.

👉 Pro tip: Submitting signature logs or attestations up front can prevent delays with contractors like RACs, CERT, and MACs.

At the end of the day, Medicare reviewers are less interested in your penmanship style and more in whether your signature proves authenticity. So, take a second to sign—it might just save your claim! ✅

09/03/2025

🧾 Prior Auth Rule: Faster Answers, Fewer Headaches (we hope)

Good news (with a compliance twist): CMS finalized big prior authorization changes that should speed things up—for payers and for your patients.

What’s changing?
• Certain payers (including Medicare Advantage) must issue PA decisions within 7 calendar days (standard) and within 72 hours (expedited). Starts Jan 1, 2026. CMS
• CMS is also pushing payers to modernize with APIs (tech rails for PA + data sharing). Most API pieces land by Jan 1, 2027. CMS

Why practices should care:
• Faster PA decisions = fewer limbo days for scheduling and cash flow.
• Clearer denial reasons must be provided, which helps your team fix & resubmit without guesswork. CMS

Where this applies:
• Impacts Medicare Advantage, Medicaid/CHIP, and certain Marketplace plans (QHP issuers). Traditional Medicare fee-for-service isn’t the target here, but many of your patients are on MA, so your front office still feels the difference. CMS

KLA Take: Think of this as upgrading from fax-era traffic to an express lane. You’ll still need your checklists, but the lights should turn green faster.

✅ Action for offices:
1. Map your top PA services and note which payers are impacted.
2. Tighten your documentation templates now (so you’re ready for faster resubmits).
3. Ask MA plans about their 2026 timeline and API plans for 2027.

09/03/2025

🚑📊 Medicare, Category II Codes & Your Bottom Line

Think Category II codes don’t matter because you’re billing traditional Medicare?

Think again!

These little “zero-dollar” codes don’t pay a dime directly, but they speak volumes to CMS. Why? Because Medicare uses them (and other quality reporting data) to feed into MIPS (Merit-based Incentive Payment System).

👉 Under MIPS, your practice’s performance is scored, and that score adjusts your Medicare Part B payments up or down. In fact, payment rates can swing by as much as +9% or –9% depending on your score. That’s not pocket change.

Category II codes are one of the fastest ways to prove you’re hitting quality benchmarks (like documenting blood pressure control, smoking cessation counseling, or medication reconciliation).

If you don’t report these measures, Medicare assumes you didn’t do them—ouch.

And it’s not just Medicare:
• Medicare Advantage plans and commercial insurers also use Category II codes to track quality measures. They tie them to Star Ratings and pay-for-performance bonuses.
• Translation: everyone’s watching these little codes, even if they’re not writing checks for them.

So next time you’re tempted to skip a Category II code because “Medicare doesn’t pay for that,” remember:
💡 They may not pay for the code, but they sure can pay you less if you don’t use them.

✅ KLA Tip: Think of Category II codes as the broccoli of billing. They may not be your favorite, but they help keep your Medicare reimbursements healthy.

08/27/2025

The DOJ is looking into business practices at UnitedHealth’s PBM Optum Rx, in addition to its ongoing probe into the company's Medicare billing practices.

08/27/2025

⚡️ AI in Healthcare: Friend, Not Foe (But Keep an Eye on It!) 🩺🤖

Artificial Intelligence isn’t just for Silicon Valley—it’s quietly transforming small medical practices. The good news? It’s more likely to take over your paperwork than your job. (And let’s be honest, no one will complain about that 😉).

Here’s where AI shines—and where you still need to keep your human brain switched on:

✅ AI Scribes
Tools like Nuance DAX, Suki AI, and DeepScribe “listen” to visits and generate notes. Major time-saver, but remember: HIPAA compliance is a must so verify platforms source and certification Also notes can contain errors. Always verify before signing—because AI makes guesses, and you make judgments. 🚨

✅ EHR Add-Ons (ECW, Practice Fusion, etc.)
Optional AI modules suggest codes, scrub claims, or transcribe dictation. Helpful, but beware: suggested billing codes often lean toward upcoding. Treat them like a pushy sales rep—review before you buy in. 🧐

✅ Clinical Question Prompts
Some platforms (like Isabel Healthcare, VisualDx, or Nuance DAX Copilot) can suggest diagnostic questions you may have overlooked. They’re not there to replace your expertise, but they can help catch blind spots and improve documentation. Use them as a reminder, not a decision-maker—you’re still the captain of the ship. 🧭

✅ Prescription Safety
From the start, AI has been keeping watch over drug interactions, allergies, and dosing errors. Tools like First Databank (FDB MedKnowledge), Epocrates, and integrated EHR drug-checkers flag potential problems before they reach the pharmacy. Some even suggest cost-saving alternatives or check formulary coverage. 💊 Just remember—AI can catch the obvious, but only you know the patient in front of you.

✅ Insurance Verification
Platforms like Availity, Waystar (Zirmed), and Change Healthcare confirm eligibility in real time, updating patient coverage before the appointment. They’re like digital bouncers keeping bad insurance surprises out of your waiting room. 🦸

✅ Text Reminders
Systems such as Solutionreach, Weave, and Klara text patients when an appointment is booked…and again when it’s time to schedule their next one. Because patients will forget. And then forget they forgot. 📱➡️💭

👉 The takeaway? AI can handle the sticky notes, phone tag, eligibility calls, and even flag risky prescriptions. But it’s not your replacement—it’s your sidekick. You provide the care, the compassion, and the compliance.

Now you’ve got more time for what matters—your patients (and maybe sneaking in that second latte ☕).

08/25/2025

HIPAA Compliance in 2025: What Private Practices Need to Know 🩺💻

HIPAA rules are changing—and small, privately owned practices need to stay sharp. Between cyberattacks, new technology, and federal rule updates, the compliance landscape is shifting fast. Here’s a clear look at what’s in place now, and what’s on the horizon.

Where We Are Today 📌

Rising cyber threats: Healthcare saw a huge increase in ransomware attacks in 2024. Regulators are pushing for stronger safeguards like 🔐 encryption, 🔑 multi-factor authentication, and 👩‍💻 phishing-awareness training. (Source: Reuters)

Patient rights and record access: The Office for Civil Rights (OCR) continues to focus on patients’ rights to their medical records. Practices must respond quickly and without unnecessary barriers.

Privacy updates: Recent rules expanded protections for substance use disorder records and reproductive health information. While some portions were challenged in court, practices are still expected to update their Notice of Privacy Practices by early 2026. (Source: HHS)

What’s Coming Next ⏳

In January 2025, the Department of Health and Human Services proposed major changes to the HIPAA Security Rule. If finalized, they would raise the bar significantly. Highlights include:

⚡ Making all safeguards mandatory (no more “addressable” options)
📊 Annual technical inventories of all systems handling patient data
🤝 Stronger vendor oversight with rapid breach reporting
🔐 Mandatory MFA and encryption
📝 Written incident response & recovery plans, with 72-hour system restoration
🕵️ Annual audits, scans, and pe*******on tests
🚪 Faster off-boarding—removing employee access within an hour of termination

What This Means for Private Practices 🏥

Smaller practices often don’t have the IT resources of big hospitals—but regulators aren’t lowering the bar. The new expectations mean:

Risk analyses must be documented and updated every year

MFA, encryption, and anti-malware are becoming baseline requirements

Vendors must prove compliance and notify quickly of any issues

Staff training has to be ongoing, not just once a year

Policies & audits need to be written, tested, and stored

Staying Ahead ✅

The message is clear: HIPAA compliance is no longer a “check-the-box” exercise. It’s an ongoing process of protecting patient data, keeping systems secure, and building trust.

For private practices, that means:
✨ Review and update policies now
✨ Implement MFA, encryption, and recovery plans
✨ Partner with compliant vendors
✨ Train your staff regularly

Final Word 🌟

Healthcare compliance is ultimately about trust 🤝. Patients count on providers to protect their most personal information. By preparing now, practices can avoid penalties AND show patients that privacy and security come first.

08/18/2025

⚖️ OIG Audits Are Up: CCM & RPM Under the Microscope

The OIG is stepping up audits of Chronic Care Management (CCM) and Remote Patient Monitoring (RPM). If you’re billing these services, it’s time to double-check that your workflows aren’t just efficient—but compliant.

Spotlight: “Incident To” Rules
• Services must be provided under the supervision of the billing practitioner.
• Staff must act within their state-defined scope of practice.
• Only eligible providers (e.g., physicians, certain NPs, PAs) can submit the claim.

State Scope Matters
Take Tennessee, for example:
• NPs in private practice must have a collaborative agreement with a physician.
• NPs employed by a physician typically function as extenders—following up on the diagnosis and treatment plans established by the supervising physician.

So while the OIG audits are national, enforcement always considers state-specific scope of practice. What qualifies as compliant patient care in a full practice state (like Oregon or Arizona) may require physician oversight in a restricted practice state like Tennessee.

✅ CCM Billing Refresher (CPT 99490, 99439, 99487, 99489)

99490 Non-complex CCM ≥20 minutes/month Non-complex Clinical staff under physician/QHP Monthly Patient consent + care plan

99439 Non-complex CCM add-on Each additional 20 minutes Non-complex Clinical staff under physician/QHP Monthly (up to 2x) Add-on to 99490

99487 Complex CCM ≥60 minutes/month Moderate/high MDM Clinical staff under physician/QHP Monthly Complex conditions, revised plan

99489 Complex CCM add-on Each additional 30 minutes Moderate/high MDM Clinical staff under physician/QHP Monthly Add-on to 99487 (not with 99490)

Note: These codes cover non-face-to-face services. Consent and a comprehensive care plan are required.

✅ RPM Billing Refresher (CPT 99453, 99454, 99457, 99458)

99453 Initial device setup + patient education One-time

99454 Device supply & data transmission (≥16 days/30 days) Every 30 days

99457 First 20 minutes RPM services (interactive communication) Monthly

99458 Each additional 20 minutes (interactive communication) Monthly (recommend ≤2x)

Note: RPM requires an FDA-defined device, documented patient consent, medical necessity, and
interactive communication. Contracts with vendors should clearly outline these requirements.

Recent Example
In 2025, the DOJ settled with a remote monitoring company for $1.29M over improper RPM billing: missing devices, inadequate data collection, and even kickbacks.

If you provide these services—especially if you contract with an outside firm—now’s the time to review your procedures. Done right, CCM and RPM improve patient care. Done poorly, they put both patients and providers at risk. A strong reminder that compliance isn’t optional—it’s essential.

08/18/2025

From the trenches…

08/16/2025

🚨 Our clients are reporting denials for ear washing (cerumen removal) 👂

If you’ve been scratching your head about how to bill for earwax removal, here’s the quick scoop:

Two Different CPT Codes:
1. 69209 – Irrigation/Lavage, unilateral (no instruments) 🚿
• National CMS non-facility rate (2025): ≈ $15.20

2. 69210 – Removal requiring instrumentation, unilateral 🛠️
• National CMS non-facility rate (2025): ≈ $46.58
• Instruments = curettes, suction devices, forceps, or microscope.
• And no, a Starbucks stopper does not qualify as an instrument ☕😂

👉 Laterality matters:
• LT = left ear
• RT = right ear
• 50 = bilateral (both ears)
⚠️ Some MACs don’t accept 50 with 69210—require LT/RT on separate lines. Check your local MAC policy.

Specialty-driven coverage 📋
• ENTs and PCPs usually get smoother approvals if medical necessity is documented so that takes you beyond impacted cerumen. What problem is impacted cerumen causing?
• Audiologists: if wax removal is same day as diagnostic testing, use G0268 (not 69209/69210).

ICD-10 Codes to Support Medical Necessity 📑
Impacted cerumen:
• H61.21 – Right ear
• H61.22 – Left ear
• H61.23 – Bilateral
Hearing loss (unspecified type):
• H91.91 – Right ear
• H91.92 – Left ear
• H91.93 – Bilateral
Otalgia (ear pain):
• H92.01 – Right ear
• H92.02 – Left ear
• H92.03 – Bilateral
(Tip: if you know the specific type of hearing loss—conductive, sensorineural, etc.—use that more specific ICD-10 instead.)

Why denials happen ❌
Many Medicare Advantage and HMO plans consider ear cleaning “bundled” and won’t pay unless tied to a primary diagnosis such as hearing loss or pain.

Documentation pearls ✍️
• Note the symptom/diagnosis (e.g., H61.23, H91.93, or H92.03).
• Specify method used (irrigation vs curette/suction).
• Indicate which ear(s).
• Include pre- and post-removal exam findings.

💡 Bottom line: Earwax billing is trickier than it looks. Choose the right CPT, pair it with the correct ICD-10, document necessity, and don’t let the payers stir things up (leave that to Starbucks).


😂

08/13/2025

The Latest from CMS: What Private Practices Need to Know

Today, Dr. Mehmet Oz—confirmed as CMS Administrator on April 8, 2025—has launched a suite of initiatives that may significantly affect how private practices navigate billing, compliance, and operations. Here are the key developments:

1. Sharper Medicare Advantage Audits

Dr. Oz has ramped up enforcement on Medicare Advantage billing. He estimates insurers may be overbilling by up to $40 billion annually, prompting CMS to hire 2,000 new staff to conduct audits in the coming months.(See attached MarketWatch article)

Impact on Private Practices: If you submit or review claims for Medicare Advantage patients, audit risks may rise. Ensuring precise documentation and accurate coding is more critical than ever.

2. Streamlined Prior Authorization via Industry Pledge

In June 2025, CMS secured commitments from major insurers to overhaul prior authorization procedures. Highlights include:

* Standardizing electronic submissions with FHIR-based APIs
* Reducing the number of services requiring authorization by 2026
* Ensuring continuity of authorizations during insurance transitions
* Implementing real-time approval capabilities by 2027.

Impact on Private Practices: Administrative burden could ease significantly, improving turnaround on care approvals and reducing staffing headaches.

3. Aggressive Crackdowns on ACA & Medicaid Fraud

CMS is actively targeting improper enrollments in ACA plans—of which up to 5 million cases may involve fraud.

New rules aim to lower premiums (\~5%) and save approximately $ 12 billion by 2026. Additionally, CMS is closing loopholes used by some states to redirect Medicaid funds improperly.

Impact on Private Practices: Expect stricter verification processes. Billing teams may need to invest extra time in confirming patient eligibility to remain compliant.

4. Vision for Digitization and Prevention

In his April 2025 address, Dr. Oz emphasized several guiding goals for CMS:

* Empowering patients with cost transparency
* Reducing administrative tasks for providers
* Shifting the focus from “sick care” to prevention and wellness
* Leveraging digital tools to modernize Medicare & Medicaid system

Impact on Private Practices: Practices that adopt more patient-facing cost tools and embrace digital workflows now may thrive under these evolving expectations.

The plan to investigate the private health-insurance companies that run Medicare Advantage has been drastically expanded.

07/17/2025

🩺💻 HIPAA 101: People Over Paperwork, but Privacy Still Matters!

Let’s talk HIPAA—the Health Insurance Portability and Accountability Act. Sounds complicated, right? 😵‍💫 But the heart of HIPAA is simple: it’s about protecting our patients’ personal health information (PHI) while still making sure they get the care they need. ❤️

Did you know? 📘 According to 45 CFR § 164.502(j), the HIPAA Privacy Rule includes a commonsense exception: if a provider believes a patient is in serious danger, patient safety and well-being take priority over the technicalities of privacy. In other words, HIPAA is not meant to be a barrier to saving lives. 🚑💡

That said, HIPAA violations are still a big deal—especially the ones that can be avoided with a little office TLC. 🧽✨

Here are some common HIPAA slip-ups we still see in healthcare settings:

📧 Using unsecured email to send patient information.
💬 Discussing cases in public areas (hallways, elevators, waiting rooms).
📋 Leaving charts out in plain sight or computers unlocked.
📸 Posting on social media without de-identifying patient details—even if it’s well-intended.

And what are the feds cracking down on lately? 👮‍♂️⚖️

• The OCR (Office for Civil Rights) has been investigating unlawful disclosures through social media (like staff oversharing online).
• Fines have also been issued for not giving patients timely access to their records—this is a right, not a privilege!
• Another biggie: failure to conduct risk assessments or encrypt devices that store PHI.

👉 Bottom line: Yes, we must protect patient information. But no, we don’t let fear of “breaking HIPAA” keep us from doing the right thing—especially in emergencies. 🆘

📚 References & Further Reading:
• HHS.gov HIPAA Guidance
• 45 CFR § 164.502(j) - Preventing or lessening a serious threat
• OCR HIPAA Enforcement Highlights

HHS Accessibility & Section 508

07/10/2025

“Medicare Food Card?” Yes, It’s a Real Thing (And It Might Just Pay for Your Bananas)

If you’ve heard whispers about a “Medicare food card” and thought it sounded too good to be true—like kale that actually tastes like chocolate—let’s clear the air.

🍎 What Is the Medicare Food Card?

The “Medicare food card” is not a new government handout or a secret senior citizen club perk (although that would be cool). It's a benefit offered by certain Medicare Advantage (Part C) plans...NOT BY TRADITIONAL MEDICARE.

These plans sometimes include a prepaid debit card that can be used to buy approved grocery items, over-the-counter medications, and other essentials.

Think of it like a reloadable grocery gift card that comes from your health plan.

💳 What Does It Cover?

Coverage depends on your specific Medicare Advantage plan, but generally, these cards can be used for:

Healthy groceries: Fruits, veggies, lean meats, dairy, whole grains.

Over-the-counter items: Pain relievers, vitamins, first-aid supplies, cold remedies.

Occasionally transportation or utility assistance, depending on the plan.

It’s not a blank check for lobster bisque and fancy cheese trays, but it can help cover real food and health-related expenses.

Some plans offer $25–$275 per month, and the money usually doesn’t roll over—so use it or lose it!

😎 Who Gets It?

These food cards are often targeted toward:

Low-income individuals who qualify for both Medicare and Medicaid (known as "dual eligibles")

Members of Special Needs Plans (SNPs) or certain other Medicare Advantage plans

Not all plans offer this, so check your plan’s Evidence of Coverage (EOC) or call customer service for your plan.

💵 Is It Taxable?

Now for the IRS question. Here’s the good news:

The Medicare food card is not considered taxable income. 🙌

It’s classified as a health-related benefit, not income. So Uncle Sam isn’t interested in your apple money.

Still, it’s smart to keep receipts and records, just in case your accountant wants backup.

🥕 Bottom Line

The Medicare food card is a sweet (and savory) deal if your plan offers it. It won’t replace your whole grocery budget, but it’s a helpful perk—especially when food prices are doing cartwheels.

If you're not sure whether your plan includes this benefit, ask your doctor’s office for help or call your plan directly. They are happy to help patients navigate benefits, because honestly, insurance is like alphabet soup—and nobody wants to choke on a PPO!

Want to know more, here's a YouTube on point.

The Medicare food allowance card is a valuable resource for seniors striving to maintain a nutritious diet on a fixed income. This supplemental benefit is of...