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Medical Association of Billers

The Medical Association of Billers (MAB). Founded in 1995, MAB is the premier credentialing.

Medical billing certification, consulting, training, education, networking

01/03/2024

Happy Wednesday Afternoon and Happy 2024!

Health system leaders predict VBC growth in next 3 years.

Healthcare leaders predict that tightening margins and rising costs will push health systems to focus more on value-based care initiatives in the next three years. Greg Poulsen of Intermountain Health thinks organizations will face financial challenges in the next three years and look for ways to boost value while lowering care costs, Nashville General Hospital CEO Joseph Webb says the prevalence of health inequities will likely lead to the growth of "value-based initiatives designed to improve health outcomes, population health management, and reduce costs among statistically indicated at-risk populations."

https://www.beckershospitalreview.com/finance/health-system-execs-see-a-value-based-care-tidal-wave-ahead.html

Healthcare leaders have been talking about the transition to value-based care for years, but without significant movement away from fee for service. In the next

11/29/2023

Good Wednesday Morning!

The Broken Medicare System Is Forcing Physicians Out
November 22, 2023.

Yet another physician pay cut will prevent timely access to care
In any career, 25 years of dedicated work is a lot to let go of. In medicine, it amounts to hundreds of patient relationships, and the blood, sweat, and tears that go into starting and maintaining a practice.
Yet, after all that time, one of my physician colleagues recently had to let go of her beloved private practice -- not by choice and not without tears for her dear, elderly Medicare patients who now face fewer options for care. Her story is unfortunately not unique.

https://www.medpagetoday.com/opinion/second-opinions/107450?xid=nl_secondopinion

Yet another physician pay cut will prevent timely access to care

11/16/2023

Good Thursday Morning!

Humana's ACO saved Medicare over $25M last year.

Humana's accountable care organization that participated in the Global and Professional Direct Contracting model saved Medicare more than $25 million in 2022, according to CMS data. Humana's CenterWell unit, which also joined the model, generated over $2.1 million in net savings for Medicare, while Aetna's ACO saved the program about $307,567.

https://www.beckerspayer.com/payer/how-payers-acos-fared-in-2022.html

Humana's ACO saved $25.6 million for the Medicare program in 2022. Several payers' ACOs participated in the Global and Professional Direct Contracting model, with Humana recording the highest savings.

11/14/2023

Good Tuesday Morning!

HHVBP participants saved Medicare $1.38B in 6 years.

A CMS report showed the nine states that participated in the Home Health Value-Based Purchasing Model achieved $1.38 billion in savings for Medicare during the first six years of the program before the national expansion early this year. The reductions in Medicare spending was mainly driven by decreases in inpatient hospitalization stays, home health spending, and skilled nursing facility services.

https://homehealthcarenews.com/2023/10/home-health-agencies-made-the-hhvbp-model-demonstration-a-resounding-success/

In the first six years of the Home Health Value‐Based Purchasing (HHVBP) Model demonstration, the nine participating states saved Medicare $1.38 billion,

11/02/2023

Good Thursday Morning!

Medicare, MA enrollment period under way.

The Medicare open enrollment period has begun and will continue until December 7, offering older adults the opportunity to select either a traditional Medicare or privately operated Medicare Advantage plan as well as coverage for prescription drugs. A KFF survey indicated that about a third of enrollees tend to compare their coverage choices during enrollment season.

https://apnews.com/article/medicare-advantage-open-enrollment-bec0ef210163d637944d6d81ddbdbd66

Open enrollment for Medicare opens Sunday, and seniors could have dozens of options to choose from. During the enrollment period, which ends Dec. 7, people will have the opportunity to choose between traditional Medicare and privately run Medicare Advantage plans in their area, as well as prescripti

11/01/2023

Good Wednesday Morning!

Health insurers' customer satisfaction scores hit record high.

A report from the American Customer Satisfaction Index found that overall consumer satisfaction scores for health insurers jumped 4% to a record 76 points out of 100 possible points this year. Humana, Aetna, Centene, Kaiser Permanente and Cigna were among the insurers with the highest satisfaction scores. "Despite rising costs, consumers are more impressed with both the quality and value of their health insurance, and the improvement extends across the entire policyholder experience, including mobile apps," according to Forrest Morgeson, director of research emeritus at ACSI.

https://www.beckerspayer.com/payer/top-ranked-insurers-for-customer-satisfaction.html

Customer satisfaction with health insurers is up 4% over 2023, according to the American Customer Satisfaction Index. Humana scored highest with 82, while Cigna had the lowest score.

10/31/2023

Good Tuesday Morning!

Affordability is the greatest concern in paying medical bills.

Research from patient financial engagement company Cedar shows that about three-quarters of consumers consider affordability to be the most significant challenge in handling their large medical bills, while 58% say paying their bills is stressful and 18% have trouble understanding their benefits and costs. The company suggests solutions such as offering consumers payment flexibility and boosting collaboration between payers and providers.

https://www.benefitspro.com/2023/10/18/consumers-cite-affordability-as-biggest-issue-when-paying-health-care-bills/?slreturn=20230931091130

58% of people find paying a health care bill to be stressful.

10/25/2023

Good Wednesday Morning!

Some Doc Bonuses From Employers Safe From Anti-Kickback Violation.

If your employer pays you a bonus based on the volume of certain procedures performed, could you be at risk for an Anti-Kickback law violation? As long as you're an employee, you're likely safe, according to the Department of Health and Human Services Office of Inspector General (OIG).
In an advisory opinion posted October 13, the OIG said receiving a physician bonus based on the profits of certain outpatient procedures performed does not violate the federal Anti-Kickback statute (AKS).

https://www.medscape.com/viewarticle/997457?ecd=wnl_dne10_231018_MSCPEDIT_etid5966304&uac=439796PG&impID=5966304

In a new advisory opinion, the Office of Inspector General clarifies when a physician bonus based on certain procedures performed could be considered an Anti-Kickback law violation.

10/20/2023

Good Friday Morning!

Prior Authorization Software: Saves Time but Hurdles Remain.

New England Baptist Hospital has been grappling with a serious problem facing healthcare today — insurers demanding prior authorizations for services ordered by physicians. Meeting payers' requirements eats up time, delays treatment, and can be a costly drain on doctors' practices.
To deal with this problem, the Boston Orthopedic Hospital has opted to automate submission of prior authorization requests on behalf of more than 100 mostly orthopedic surgeons on staff.

https://www.medscape.com/viewarticle/997446?ecd=wnl_dne1_231018_MSCPEDIT_etid5966304&uac=439796PG&impID=5966304

Many organizations have started to automate prior authorization requests. They save physicians time, but the software still has a way to go.

10/16/2023

It is Monday, October 16, 2023! Good Afternoon!

CMS: Medicare Part B premiums to increase next year.

CMS announced that the standard Medicare Part B monthly premium will increase from $164.90 this year to $174.70 in 2024, primarily due to expected growth in healthcare spending. The annual deductible will increase by $14 to $240 for Part B and by $32 to $1,632 for Part A inpatient hospitalization, and the standard premium for elective Part B coverage of immunosuppressive drugs will be set at $103.

https://www.healthcarefinancenews.com/news/cms-releases-2024-medicare-parts-and-b-premiums-and-deductibles

Premiums and deductibles for Part B physician and outpatient care are both increasing next year.

10/11/2023

Good Wednesday Morning!

Should 'Site Neutrality' Be Used to Set Payments?

"I don't think 'site-neutral' is neutral," one commissioner says.
Should "site neutrality" -- the idea of paying the same rate for the same service no matter where it is provided -- be applied when it comes to setting Medicare payment rates? Nope, says Medicare Payment Advisory Commission (MedPAC) member Lynn Barr, MPH.

https://www.medpagetoday.com/medical-journeys/heart-failure/105959

Treatment across the heart failure spectrum

10/10/2023

Good Tuesday Morning!

Survey explores consumer issues with claims denials.

About 60% of adults have issues with denied claims, prior authorization delays and denials, and network adequacy, according to a KFF survey. People with employer-sponsored or marketplace insurance were more likely to have claims denied than those with Medicare or Medicaid, and people who have more than 10 visits per year had a higher likelihood of experiencing a denied claim than those who have fewer than 10 visits annually.

https://www.kff.org/health-reform/issue-brief/consumer-survey-highlights-problems-with-denied-health-insurance-claims/

This Data Note includes major findings from the KFF Consumer Survey on consumer experiences with claim denials. Among those who used the most health care over the past year, 27% experienced a denied claim. More consumers with private insurance experienced denied claims compared to Medicaid or Medica...

10/09/2023

It is Monday, October 9, 2023! Good Morning!

Most insurers, providers: VBC programs were successful.

A Terry Health survey found that a majority of insurers, health care providers and payviders believed their value-based care programs had been somewhat successful in enhancing clinical outcomes and patient experience while controlling health care spending. Respondents already implementing VBC programs were more optimistic about the potential of value-based care than those who had plans or no plans of engaging in VBC.

https://www.fiercehealthcare.com/payers/terry-health-survey-payers-providers-sentiments-value-based-care

Most providers, payers and payviders believe their value-based care (VBC) programs to date have been somewhat, not very, successful, a recent survey has found. | A Terry Health survey sought to identify areas in which the value-based care experience of providers, payers and hybrids aligned or were a...

10/06/2023

Good Friday Afternoon!

Wis. bill would alter prior authorization for some services.

A bill in Wisconsin would require payers to decide authorization for a covered service within 48 hours or prior authorization would be assumed, prevent prior authorization requirements for chronic pain for the first 90 days of treatment, and ban the use of evidence of outcomes to create approval policies, among other measures. The changes would affect a number of healthcare services, including physical, occupational, and speech therapy.

https://www.wisbusiness.com/2023/gop-bill-aims-to-change-prior-authorization-process-for-certain-health-services/

GOP bill aims to change prior authorization process for certain health services September 26, 2023 GOP lawmakers are seeking to make changes to the prior authorization process in Wisconsin, in which health care providers have to get an OK from insurers for certain medical services. Sen. Patrick Te...

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

09/28/2023

Good Thursday Morning!

Digital healthcare coverage inconsistent among payers.

Medicare and Medicare Advantage plans typically cover and reimburse for remote patient monitoring, remote therapeutic monitoring, interprofessional consultations, and digital evaluation and management, according to a report from the American Medical Association and Manatt Health. However, Medicaid virtual health care coverage varies, as does coverage from 16 commercial payers evaluated.

https://www.politico.com/newsletters/future-pulse/2023/09/19/where-digital-health-coverage-lags-00116612

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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.

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Online Medical Billing Training! July 2021 | 16 hours of interactive instructor-led training | Prepare for certification | Refresh your knowledge | Learn about medical and insurance terminology, commercial insurance, Medicare, other government payers, billing process and office functions, laws and ethics, ICD-10-CM coding, CPT® coding, HCPCS coding, and revenue cycle management. Classes are small, so register now! https://mabillers.com/join-%7C-renew-%7C-shop/ols/products/powerweek

Our next online training is scheduled for the week of July 19-23. Interested in learning about Medical Billing? Need to get your staff certified? Register now for 16 hours of interactive training to learn medical billing basics and prepare to sit for the Certified Medical Billing Specialist® exam. We keep class sizes small, so register now! https://mabillers.com/join-%7C-renew-%7C-shop/ols/products/powerweek