Medical Association of Billers

10/04/2023

Good Wednesday Morning!

Two Large Medical Groups Shun Medicare Advantage Plans.

San Diego doctor groups latest to withdraw, citing low pay, prior authorization problems.

Signaling what may be an emerging national trend, two influential medical groups with San Diego-based Scripps Health are canceling their Medicare Advantage contracts for 2024 because of low reimbursement and prior authorization hassles, leaving 30,000 enrolled seniors to look for new doctors or different coverage.

https://www.medpagetoday.com/special-reports/exclusives/106483?xid=nl_mpt_DHE_2023-09-

San Diego doctor groups latest to withdraw, citing low pay, prior authorization problems

10/03/2023

Good Tuesday Morning!

Hospitals' online prices don't match prices offered by phone.

A study published in JAMA Internal Medicine showed variation in hospitals' online prices for vaginal childbirth and brain magnetic resonance imaging versus the telephone prices obtained by secret shoppers, with the price difference often reaching 50%, and sometimes over 100%. "These results demonstrate hospitals' continued problems in knowing and communicating their prices for specific services," researchers noted, adding "the findings also highlight the continued challenges for uninsured patients and others who attempt to comparison shop for healthcare."

https://www.fiercehealthcare.com/providers/hospitals-online-over-phone-cash-prices-rarely-align-study-finds

Patients checking their local hospital’s website for the cost of medical services may not find the same prices as those who called on the phone, according to a newly published study. | The comparison of 60 hospitals' listed prices and those obtained by secret shopper callers "highlight the continu...

10/02/2023

Good Monday Morning! It is October 2, 2023!

How a shutdown would affect health care.

If lawmakers can't reach a consensus on a funding deal, Medicare, Medicaid and the Affordable Care Act marketplace would keep operating, the FDA would continue to review medical device and drug applications, and emergency public health measures and outbreak responses would remain, as would medical care under the Department of Veterans Affairs. However, about 42% of HHS staff and some VA staff would be furloughed, and the CDC says some public health activities would function at a reduced capacity.

https://www.washingtonpost.com/politics/2023/09/25/what-government-shutdown-means-health-care/?wpisrc=nl_sb_smartbrief&utm_campaign=902EC53C-E741-4B61-BD05-1791894901B4&utm_content=EDF8F9A0-A31F-48AF-B0DC-4031B48935FA

Forty-two percent of HHS workers would be furloughed even as Medicare, Medicaid benefits continue.

09/29/2023

Good Friday Morning!

A SAD Story: Patient has $176K Bill After Medicare Policy Switch.

CMS abruptly decided patients can self-administer Stelara -- even those with Parkinson's.

https://www.medpagetoday.com/special-reports/exclusives/106338?xid=nl_mpt_investigative2023-09-

CMS abruptly decided patients can self-administer Stelara -- even those with Parkinson's

09/26/2023

Good Tuesday Morning!

The dark side to eliminating prior authorization.

Some health care providers say that insurers' prior authorization rules needlessly delay provision of needed health care, but completely eliminating prior authorization requirements could result in more denied claims, writes orthopedic surgeon Chukwuka Okafor. "Prior to performing any procedure/treatment, if the insurance company tells you no authorization is needed, make sure you have the insurance company provide you in writing the list of diagnoses for which no prior authorization applies," Okafor suggests.

https://www.beckersspine.com/spine/57790-the-hidden-danger-regarding-elimination-of-prior-authorization-for-certain-medical-and-surgical-service.html

Learn about the potential pitfalls of insurance companies eliminating prior authorizations for certain medical/surgical services, and how it can lead to medical

09/25/2023

It is Monday, September 25th, 2023! Good Morning!

CMS unveils new total cost-of-care reduction model for states.

The CMS said it will be collaborating with state governments to improve overall population health and care quality while addressing healthcare disparities and reducing avoidable spending through a new total cost-of-care reduction payment model. The States Advancing All-Payer Health Equity Approaches and Development Model, the new iteration of the CMS' multipayer total cost of care models, will award up to $12 million each to as many as eight participating states, and the program is set to run from summer 2024 through December 2034.

https://www.beckershospitalreview.com/finance/cms-launching-population-health-focused-payment-model-for-states-hospitals.html

CMS is launching a new payment model to address chronic disease, behavioral health, and improve care management for states' populations. Up to 8 states can rece

09/21/2023

Good Thursday Morning! How is everyone this week?

Aledade, FL Blue tout $14M savings in VBC network collaboration.

Florida Blue and Aledade announced that their value-based care network collaboration in Florida generated nearly $14 million in shared savings over two years. About 59 primary care practices that participated in the Aledade-Florida Blue ACO last year "outperformed the market in rates of control of diabetes, as well as screening rates for breast cancer, colorectal cancer and cervical cancer," and the practices also saw reductions in hospitalizations and emergency department visits while raising "their rates of patient outreach through workflow management powered by the Aledade App."

https://www.fiercehealthcare.com/payers/florida-blue-aledade-tout-14m-savings-their-value-based-two-sided-risk-collaboration

Value-based healthcare with two-sided risk led to a savings of about $14 million over two years, according to the Florida-based insurance plan and national primary care provider company that overse | The collaborative effort by Florida Blue and Aledade not only led to $14 million in savings, but als...

09/20/2023

Good Wednesday Morning!

Highmark's value-based reimbursement program saved over $3B.

Highmark said its True Performance value-based reimbursement model for primary care providers has saved over $3 billion in avoided healthcare costs in Delaware, West Virginia, and Pennsylvania since its launch in 2017. The company's total avoided costs reached $106 million for emergency visits and $632 million for reduced inpatient admissions in 2022 alone. The model also kept members healthier through recommended immunizations, drug therapy for chronic conditions, cancer screenings, and annual wellness visits.

https://lvb.com/highmark-program-realizes-more-than-3b-in-avoided-cost-savings/

Highmark Inc.’s program to reduce hospital admissions and emergency department (ED) visits has seen more than $3 billion in avoided cost savings since 2017.

09/19/2023

Good Tuesday Morning!

Mich. BCBS to ease prior authorization requirements.

Blue Cross Blue Shield of Michigan is expanding its gold carding program and eliminating about 20% of prior authorization requirements. The insurer says that "most prior authorization requests are submitted electronically and approved within seconds using automation that expedites the process."

https://www.fox17online.com/news/local-news/michigan/blue-cross-blue-shield-of-mi-outlines-plans-to-deliver-faster-healthcare-access

Blue Cross Blue Shield of Michigan announced it will take additional steps to deliver faster access to healthcare.

09/18/2023

It is Monday, September 18, 2023! Good Afternoon!

NY comptroller finds health dept billing guidance inadequate.

The need for medical billing training and certification that MAB and MAB Institute offer!
The New York State Comptroller has found that the state's Department of Health has failed to provide adequate guidance for hospitals on billing practices, leading to improper billing and overpayments to Medicaid. A report found that almost 50% of the 190 claims audited were billed as inpatient care when they should have been billed as outpatient care and that $1.5 million in payments from CMS were misclassified, among other findings, and the Health Department said it will review its guidance.

https://www.crainsnewyork.com/health-pulse/state-doh-must-offer-hospitals-better-billing-guidance-avoid-medicaid-overpayments

Plus:NYU buys $210M apartment building across from its Kips Bay medical schoolJamaica Hospital Medical Center buys $10M building to expand servicesFamilies of nursing home Covid victims sue former Gov. Andrew Cuomo over pandemic policy

09/14/2023

Good Thursday Morning!

Cigna to end prior authorization for 600-plus procedures.

Cigna plans to remove prior authorization requirements from 25%, or over 600, of the procedures in its commercial plans, including those involving genetic testing, surgery and diagnostics. Additionally, the insurer will remove prior authorization for 500 codes under its Medicare Advantage plans.

https://www.reuters.com/business/healthcare-pharmaceuticals/cigna-removes-pre-authorization-requirement-25-medical-services-2023-08-24/

Health insurer Cigna Group said on Thursday it would remove the use of prior authorization or paperwork required to get approval for insurance coverage for 25% of medical services.

09/12/2023

Good Tuesday Morning!

UHC to pay $80K, create an action plan in HHS settlement.

The HHS Office of Civil Rights settled accusations that UnitedHealthcare violated a HIPAA Privacy Rule provision that allows patients to have timely access to their medical records. UnitedHealthcare will pay $80,000 and implement a corrective action plan to resolve the allegations.

https://www.healthcarefinancenews.com/news/unitedhealth-pays-80000-settle-hipaa-allegations

A patient requested his medical records and did not receive them for six months - after the OCR stepped in - agency says. 

09/11/2023

It is Monday, September 11, 2023! Good Morning!

Judge sides with providers in 4th suit against No Surprises Act.

US District Judge Jeremy Kernodle has again ruled against HHS in a lawsuit filed by the Texas Medical Association that challenged certain provisions of the No Surprises Act related to the calculation of the "qualifying payment amount" used during arbitration. In his Aug. 24 ruling, Kernodle said "all but one regulation pertaining to the calculation of the QPA violate the plain text of the Act."

https://www.fiercehealthcare.com/providers/texas-docs-fourth-courtroom-win-over-hhs-interrupts-out-network-billing-arbitration-yet

The Texas Medical Association (TMA) is now 4-0 on its legal challenges to the Biden administration’s rocky implementation of the No Surprises Act, which bans surprise out-of-network medical bills a | The ruling over calculation of the qualifying payment amount used during independent dispute resol...

09/06/2023

Good Tuesday Evening!

Doctors, Patients Try to Shame Insurers to Reverse PA Denials.

Many have taken to social media to get tests, drugs, and treatments approved.

https://www.medpagetoday.com/special-reports/features/106041?xid=nl_mpt_DHE_2023-08-

Many have taken to social media to get tests, drugs, and treatments approved

08/28/2023

It is Monday, August 28, 2023! Good Morning!

Minn. AG to investigate billing practices at Allina Health.

The Minnesota office of the Attorney General is investigating the billing practices of Allina Health after a New York Times article reported that the health system cut off nonemergency medical care to patients with outstanding bills, and the company has since paused the policy. An agreement established in 2005 by the state attorney general's office prohibits unfair billing and collections practices and requires hospitals to offer payment plans to patients, and legislation signed by Gov. Tim Walz this year mirrors the agreement.

https://www.healthcarefinancenews.com/news/allinas-medical-billing-practices-under-investigation-minnesota-ags-office

In 2022, the AG launched an investigation into Mayo Clinic, which is ongoing.

08/24/2023

Good Thursday Afternoon!

Our Certified Medical Billing Specialist course is coming up in September!

This is a huge opportunity to get CERTIFIED and CREDENTIALED as a medical biller.

Take a look at the link below or shoot us a message right here on LinkedIn.

Take a big step in your career and become a CERTIFIED Medical Billing Specialist (CMBS) today!

P.S. Members get a $200 discount!

#1995

MAB Institute offers PowerTraining™ to provide 16 hours of online, instructor-led medical billing and coding training over five Tuesdays - a PowerMonth™! While it is impossible to teach you everything about medical billing and coding in 16 hours, you will receive a solid foundation on which to b...

08/23/2023

Good Wednesday Morning!

Lobbying Allowed Insurers to Charge Docs $ for Online Payment.

An insurance industry lobbying campaign persuaded federal officials to allow insurers to charge physicians fees for the privilege of being paid electronically, even though it can cost more to mail paper checks, according to a new investigation by the nonprofit news organization ProPublica.

https://www.medscape.com/viewarticle/lobbying-allowed-insurers-charge-docs-receive-payments-2023a1000jdl?ecd=wnl_dne2_230822_MSCPEDIT_etid5775308&uac=439796PG&impID=5775308

Physicians shouldn't have to pay large fees to receive insurers' payments electronically under the Affordable Care Act. But lobbyists convinced federal officials otherwise, according to a ProPublica news investigation.

08/22/2023

Good Tuesday Afternoon!

N.C. hospitals sue thousands of patients for medical debt.

An analysis of court records found North Carolina hospitals and health systems have filed a total of 5,922 debt collection lawsuits against over 7,500 patients and their family members between 2017 and 2022, and former public hospital system, Atrium Health, accounted for nearly a third of the legal actions. The lawsuits generated over $57 million in judgments for the health systems and hospitals, including millions of dollars in interest charges and other fees, according to a report from the North Carolina state treasurer and Duke University School of Law researchers.

https://kffhealthnews.org/news/article/north-carolina-hospitals-patient-debt-lawsuits/

An analysis of court records by the state treasurer and Duke researchers finds Atrium Health, originally a public hospital system, accounted for almost a third of the legal actions against North Ca…

08/21/2023

It is Monday, August 21, 2023! Good Morning!

Insurers take steps to improve prior authorization.

Health insurers are implementing various strategies to improve the prior authorization process, which aims to reduce health care costs and limit unnecessary procedures, amid concerns that the process could lead to care disruption and increased administrative burden. Aetna, for instance, eliminated pre-certification requirements for cataract surgeries for most plan members as well as prior authorization for physical therapy services in five states, while Humana made similar changes by ending prior authorization requirements for cataract surgeries among Medicare Advantage members in Georgia. Health Care Service Corporation, meanwhile, leveraged artificial intelligence and algorithms to streamline and expedite prior authorization approvals.

https://healthpayerintelligence.com/news/how-payers-are-reducing-prior-authorizations-limiting-care-disruptions

As prior authorization scrutiny persists, payers have started to reduce requirements and limit care disruptions.

08/16/2023

Good Wednesday Morning!

CMS reinstates a $50 IDR fee after the court ruling.

CMS announced that it is reverting from a $350 to a $50 per party fee for settling payment disputes under the No Surprises Act and removing the restrictions that prevented physicians from batching similar claims in one dispute, in response to a federal judge's ruling that temporarily halted the independent dispute resolution process. The CMS said the HHS, Labor, and Treasury departments will inform interested parties once they decide to reopen the Federal IDR portal and permit the submission of new disputes.

https://radiologybusiness.com/topics/healthcare-management/healthcare-policy/cms-officially-drops-fee-independent-dispute-resolution-back-50

The agency has not yet announced the reopening of the Federal IDR portal to submit new disputes, with the feds hoping to do so "soon."

08/15/2023

Our Certified Medical Billing Specialist course is coming up in September!

This is a huge opportunity to get CERTIFIED and CREDENTIALED as a medical biller.

Take a look at the link below or shoot us a message right here on LinkedIn.

Take a big step in your career and become a CERTIFIED Medical Billing Specialist (CMBS) today!

P.S. Members get a $200 discount!

#1995

MAB Institute offers PowerTraining™ to provide 16 hours of online, instructor-led medical billing and coding training over five Tuesdays - a PowerMonth™! While it is impossible to teach you everything about medical billing and coding in 16 hours, you will receive a solid foundation on which to b...

08/14/2023

It is Monday, August 14, 2023! Good Morning!

Lawsuit says data analytics firm conspires to underpay claims.

AdventHealth, which runs 50 hospitals in the US, filed a lawsuit alleging data analytics company MultiPlan's cost-management software led major health insurers to underpay claims for out-of-network care. The antitrust lawsuit, which MultiPlan says is meritless, alleges that the software uses clients' real-time, confidential pricing information to fix reimbursement prices and underpay healthcare organizations by $19 billion every year.

https://www.reuters.com/legal/transactional/hospital-sues-data-analytics-company-multiplan-us-court-antitrust-case-2023-08-10/

Nonprofit hospital system AdventHealth has sued data analytics company MultiPlan in U.S. court, accusing it of leading a price-fixing conspiracy that underpaid healthcare providers billions of dollars for out-of-network reimbursements from major insurers.

08/11/2023

Medical Reimbursement for the Market Analyst Training

Begins August 31 - Register Now at www.mabreimbpros.com

The Medical Association of Billers was founded in 1995 to train and certify medical billers to support correct claim submission and appropriate payment for providers. More recently, the MAB Institute division began a training program tailored specifically to medical device manufacturer professionals. Reimbursement, sales, and marketing professionals (among others) at medical device companies must understand and speak intelligently and accurately about reimbursement issues and apply reimbursement concepts to their unique product and business goals. Our Medical Reimbursement for the Market Analyst training program helps with medical device adoption and uptake by teaching current or aspiring reimbursement professionals how to navigate the constantly changing and complex reimbursement environment. It also prepares students to sit for the Market Access Reimbursement Analyst™ certification. The training is a 40-hour, instructor-led program approved by the State Council of Higher Education for Virginia.

08/08/2023

Good Tuesday Morning! How is everyone doing so far today?

Cigna Accused of Using AI, Not Doctors, to Deny Claims: Lawsuit.

A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny "hundreds or thousands" of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.

https://www.medscape.com/viewarticle/995193?ecd=wnl_dne1_230807_MSCPEDIT_etid5724078&uac=439796PG&impID=5724078

Attorneys for Cigna health plan members say the insurer violates California law by using an algorithm to automatically deny claims, leaving hospitals and physicians to bill patients for the balance.

08/07/2023

It is Monday, August 7, 2023! Good Afternoon!

Prior Auth Reform Bill Advances, but Conflict Looms.

Federal lawmakers are pushing forward a bipartisan bill that would force some Medicare insurers to speed up their prior authorization decisions, but it may ultimately conflict with separate rules set by the agency that oversees Medicare.

https://www.medscape.com/viewarticle/995133?ecd=wnl_dne8_230804_MSCPEDIT_etid5714814&uac=439796PG&impID=5714814

US lawmakers are seeking faster Medicare Advantage decisions on prior authorization requests, but their legislation could conflict with new Medicare agency rules.

08/04/2023

Good Friday Morning!

Healthcare providers and insurers report problems with No Surprises.

Some healthcare professionals say health insurers have delayed paying arbitration awards under the No Surprises Act or have sent notices that they will not comply with arbitration awards because they believe the awards are non-binding and unenforceable, according to the advocacy group Americans for Fair Health Care. Insurers say that they have been subjected to frivolous challenges and that arbitrators have bundled decisions, leading to delays. The CMS is investigating the complaints.

https://www.axios.com/2023/08/03/insurers-refusing-pay-surprise-billing

Some doctors say insurers have refused to pay arbitration awards in surprise billing disputes.

08/03/2023

Good Thursday Morning!

CMS raises 2024 inpatient rehab, psychiatric payment rates.

The CMS has released final rules increasing overall Medicare payments rates by 4% or $355 million for care provided at inpatient rehabilitation facilities and by 2.3% or $70 million for inpatient psychiatric facilities for fiscal 2024. The final rates were higher than the rates proposed by the agency in April.

https://www.healthcarefinancenews.com/news/final-rule-increases-proposed-payments-inpatient-rehab-and-psychiatric-facilities

For both, CMS is modifying the COVID-19 Vaccination Coverage Among Healthcare Personnel measure that will affect the 2025 payments.

08/02/2023

Good Wednesday Morning!

House bill aims to extend MACRA incentive payments.

A bipartisan group of House lawmakers reintroduced legislation that would extend the 5% bonus payments furnished to participants in advanced alternative payment models under the Medicare Access and CHIP Reauthorization Act, which are slated to expire this year. Seventeen organizations sent a letter to express their support to the Value in Health Care Act, noting the bill will "maintain and further strengthen the movement towards high-quality care in which financial performance is linked to the quality of patient care rather than the number of services delivered."

https://www.beckerspayer.com/policy-updates/lawmakers-introduce-bill-incentivizing-value-based-care-in-medicare.html

Lawmakers are proposing legislation to extend incentives for value-based care in Medicare. The Value in Health Care Act would encourage providers to join altern

07/31/2023

It is Monday, July 31, 2023! Good Morning!

Prior authorization requirements for cancer drugs rise.

Prior authorization is increasingly required for oral cancer drugs on Medicare Part D formularies, particularly among non-specialty brand drugs, according to a study in JAMA Network Open. Researchers note that it's unclear why effective, first-line treatments require prior authorization, although utilization management may be appropriate for medications approved with provisional efficacy.

https://lnkd.in/gaP-GfYb

Over the past decade, the biggest increase in prior authorization occurred for non-specialty brand and generic drugs.

07/28/2023

Good Friday Afternoon!

Some health systems bill for physician messaging.

The COVID-19 pandemic sparked a significant rise in patient electronic messaging to physicians, and some hospitals and health systems have started billing individuals or insurance plans for clinician responses in an attempt to ease the burden. University of California San Francisco researcher A Jay Holmgren said physicians with a high message load tend to feel more burned out and cynical and are more likely to consider departing clinical practice.

https://lnkd.in/giihtERS

Virtual access to doctors is a huge plus for patients. But it's a lot of new work for physicians. And the health care business model hasn't caught up with this new reality.

07/27/2023

Good Thursday Morning!

Most health systems plan to increase technology spending.

Eighty-eight percent of health system IT executives say they plan to increase spending on third-party technology, according to a survey by IDC and Redox. Nearly 70% said that telehealth can help address staffing issues, and over 60% considered remote patient monitoring technology vital, 43% reported having RPM programs or investing in them, and 77% said they would have five to 20 RPM programs by next year.

https://lnkd.in/gNS2RV2p

A survey of more than 200 healthcare executives by IDC and Redox finds that despite the tough economy, health systems will be spending more on technology like AI and RPM to address workforce issues and improve clinical care pathways.