05/18/2023 Wednesday:​

On Wednesday, a Senate subcommittee asked top Medicare Advantage insurers to disclose internal documents that reveal their decision-making process for healthcare coverage. The request was made during a hearing on healthcare delays and denials under the Medicare Advantage program.

The committee is concerned about the detrimental effects of these decisions on patients needing skilled nursing care. The chairman, Richard Blumenthal, said there's increasing evidence that insurers are using algorithms, instead of medical professionals, to make care denial decisions. These decisions often affect seriously ill patients who require specialized or rehabilitation care before going home.

Blumenthal said that while these algorithms are described as mere tools by insurers, the repeated denials they cause cannot be ignored. He emphasized the need for transparency around these algorithms, which the insurers often label as proprietary.

Blumenthal also linked the continual need for prior authorizations or premature ending of certain healthcare coverages to insurers' profit motives. He shared data indicating that Medicare Advantage plans have higher profit margins per insured person compared to other insurance markets.

Letters have been sent to CVS-Aetna, United Heath, and Humana—companies that collectively cover more than half of all Medicare Advantage beneficiaries—requesting more details on their operational practices.

The Department of Health and Human Services’ Office of Inspector General testified that Medicare Advantage plans' criteria should align with original Medicare. However, she pointed out the potential incentive for insurers to deny services due to the fixed payment system in Medicare Advantage.

A report from last year highlighted the frequent denial of skilled nursing stays by Medicare Advantage plans, causing a decrease in stays and the length of such stays for skilled nursing providers.

Witnesses discussed the issues surrounding denial of skilled nursing care, highlighting that Medicare Advantage plan holders often face a complicated process to appeal their denied coverage. Patients caught in this system often have to choose between paying out of pocket or leaving the facility against medical advice. Appeals that are eventually approved can take up to a year to be reimbursed.

The hearing also examined the difficulty in controlling insurers' practices that help them manage risk. Changing these practices could lead to higher costs for the government. However, the focus of the subcommittee members seemed to be on the personal hardships caused by coverage concerns.

Personal stories shared included that of a widow from Connecticut, who detailed her struggles to secure intensive therapy for her husband following the removal of a brain lesion. The emotional and financial strain of navigating the healthcare system added to the distress of dealing with her husband's health crisis.

The committee's examination of Medicare Advantage's internal workings underscores the larger concerns about private insurance companies' role in managing public health benefits. It also draws attention to the long-debated issue of transparency in how these companies operate, particularly in their decision-making process for providing coverage.

Given the fixed payment system in Medicare Advantage, insurance companies may have financial incentives to limit services provided to beneficiaries, leading to a conflict of interest between ensuring quality care and maintaining profitability.

Testimonies and personal stories shared during the hearing highlighted this concern. They also underscored the need for reform, particularly in areas such as skilled nursing care and rehabilitation services. While these services are often crucial in recovery, they are also costly, leading to frequent denials that can delay or impede necessary treatment.

The committee expressed interest in potentially legislating to improve the situation if necessary. However, the potential for increased governmental costs presents a significant obstacle, suggesting the need for a balanced approach that ensures both adequate patient care and sustainable cost management.

An additional point of concern is the use of artificial intelligence and algorithms in decision-making. There's growing evidence that these tools may be contributing to systematic denials of care. While they may increase efficiency, there's a risk that they could lead to arbitrary or inappropriate denial of services, particularly if they are not overseen or understood adequately.

The shift to more transparency in the Medicare Advantage plans, which now cover more than half of all Medicare beneficiaries, could result in significant changes to how these plans operate and provide coverage. However, the details of these potential changes and their impact on beneficiaries, insurance companies, and overall healthcare costs remain to be seen.

As of now, the committee has put the major insurance companies on notice, seeking more information on their practices and signaling their intent to improve the system for patients who depend on Medicare Advantage for their healthcare needs.

More on this news. Read here - ​https://www.mcknights.com/news/impossible-medicare-advantage-denials-decried-during-senate-hearing/

Medicare denial codes, also known as Remittance Advice Remark Codes (RARCs) and Claim Adjustment Reason Codes (CARCs), communicate why a claim was paid differently than it was billed. These codes are universal among all insurance companies. Most of the commercial insurance companies the same or similar denial codes. Pay attention to action that you need to make in order for the claims to get paid.

Here are some common Medicare denial codes:

• CO-50: These Charges Are Denied as Non-Covered Services Because This Is Not Deemed A 'Medical Necessity' by The Payer.
  • Action: Review the necessity of the service and the documentation supporting it. If the documentation is satisfactory, you may need to appeal.
• CO-97: The Benefit for This Service Is Included in The Payment/Allowance for Another Service/Procedure That Has Already Been Adjudicated.
  • Action: Cross-verify the services provided. If you find an error, resubmit the claim.
• CO-B15: Payment adjusted because this procedure/service is not paid separately.
  • Action: No action required, as these services are typically bundled into another, more comprehensive service.
• CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
  • Action: Review the claim for any missing or incorrect information and resubmit.
• CO-125: Submission/billing error(s).
  • Action: Identify and correct the billing error, then resubmit the claim.
• CO-96: Non-covered charge(s).
  • Action: Verify if the service is covered under the patient's Medicare plan. If it is, resubmit the claim. If not, bill the patient directly.
• CO-109: Claim not covered by this payer/contractor.
  • Action: Ensure that you are submitting the claim to the correct payer/contractor.
• CO-119: Benefit maximum for this time period or occurrence has been reached.
  • Action: No action required, as the maximum benefits for the patient have been reached for the given time period.
• CO-24: Charges are covered under a capitation agreement/managed care plan.
  • Action: No action is required. The services are paid under a capitation agreement.
• CO-A1: Claim denied charges.
• Action: Review the claim to understand the reason for the denial. If it's an error, correct it and resubmit the claim.

 

• CO-26: Expenses incurred prior to coverage.
  • Action: Verify the date of service. If the service was indeed provided before the coverage start date, the patient may be responsible for the charge.
• CO-27: Expenses incurred after coverage terminated.
  • Action: Confirm the date of service. If the service was provided after the coverage termination date, the patient may be responsible for the charge.
• CO-29: The time limit for filing has expired.
  • Action: This typically can't be corrected. Claims must be submitted within the timeframe specified by the payer.
• CO-31: The patient cannot be identified as our insured.
  • Action: Verify the patient's identity and insurance details, then resubmit the claim if necessary.
• CO-45: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
  • Action: Review the charge amount. If it exceeds the allowable amount, adjust the bill and inform the patient of any balance they may owe.
• CO-58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
  • Action: Confirm the place of service code and resubmit the claim if an error was made.
• CO-81: Procedure has not been authorized by the Benefit Plan.
  • Action: Check the requirements of the patient's plan. You may need to obtain authorization before resubmitting the claim.
• CO-85: This payment is adjusted when performed/billed by this type of provider.
  • Action: Check the provider type and services rendered. Resubmit the claim if an error was made.
• CO-94: This is a duplicate of a claim processed, or to be processed, as a crossover claim.
  • Action: Verify if the claim has already been submitted and processed.
• CO-95: This item conflicts with the payer’s processing rules.
  • Action: Identify the conflict by reviewing the payer's rules and resubmit the claim with necessary adjustments.
• CO-140: Patient/Insured health identification number and name do not match.
  • Action: Verify the patient's information and correct any errors, then resubmit the claim.
• CO-151: Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
  • Action: Review the frequency and necessity of the services provided. If they're in line with standard care, you may need to provide additional documentation and appeal the decision.
• CO-170: These are non-covered services because this is a pre-existing condition.
  • Action: Check the patient's coverage details. If the condition should not be classified as pre-existing, resubmit the claim with additional information.
• CO-197: Payment adjusted for absence of precertification/authorization.
  • Action: Verify whether prior authorization was required and if so, obtain it before resubmitting the claim.
• CO-204: This service/equipment/drug is not covered under the patient's current benefit plan.
  • Action: Check the patient's coverage details. If the service should be covered, resubmit the claim with additional information or discuss other payment options with the patient.
• CO-223: Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
  • Action: Understand the specific mandate and adjust the claim accordingly before resubmitting.
• CO-237: Legislated/Regulatory Penalty.
  • Action: This code indicates that the claim adjustment is the result of a penalty as stipulated by law or regulation. No specific action may be applicable.
• CO-238: Claim spans eligible and non-eligible period of coverage.
  • Action: Separate the claim into two parts, one for the eligible period and one for the non-eligible period, then resubmit.
• CO-243: Services not authorized by network/primary care providers.
  • Action: Verify whether prior authorization was required and if so, obtain it before resubmitting the claim.
• CO-246: This non-payable code is for required reporting only.
  • Action: No specific action needed. This code is used for reporting purposes.
• Remember, these are just examples of denial codes. Each code represents a different reason why a claim might be denied, and the specific details of the claim and the patient's coverage can greatly influence the correct course of action. Always refer to the specific insurer's guidance when addressing these codes.
• CO-252: An attachment/other documentation is required to adjudicate this claim/service.
  • Action: Provide the necessary documentation and resubmit the claim.
• CO-253: Sequestration – Reduction in Federal Spending.
  • Action: No action is required. This code indicates a mandatory reduction in payment due to federal budget constraints.
• CO-16 M79: Missing/incomplete/invalid charge.
  • Action: Review the claim for any missing or incorrect charge information and resubmit.
• CO-18 M80: Duplicate claim/service.
  • Action: Verify if the claim has already been submitted and processed.
• CO-22 M81: This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
  • Action: The claim should be sent to the Worker's Compensation insurance, not Medicare.
• CO-23 M82: The equipment was rented for a 3-month period and the rental price was reached.
  • Action: No action required, as the maximum rental price has been met for the specified period.
• CO-119 N130: Consult plan benefit documents/guidelines for information about restrictions for this service.
  • Action: Check the specifics of the patient's plan and resubmit the claim accordingly, or discuss other payment options with the patient.
• CO-131 N362: The number of Days or Units exceeds our acceptable maximum.
  • Action: Verify the number of units or days of service billed. If it's accurate, you may need to provide additional documentation and appeal.
• CO-151 N640: Exceeds number/frequency approved/allowed within time period.
  • Action: Verify the frequency of the service provided. If it's accurate, you may need to provide additional documentation and appeal.
• CO-197 N95: This provider was not certified/eligible to be paid for this procedure/service on this date of service.
  • Action: Verify the provider's certification status on the date of service. If the provider was eligible, resubmit the claim.
• These codes give reasons for denials, adjustments, or informational messages that might influence the payment of a claim. Please note that the best course of action might vary based on the specifics of the claim and the patient's coverage. Always refer to the specific insurer's guidance when addressing these codes.
• CO-200: The insurance coverage is provided by a Managed Care Plan, and the member should seek care from a Managed Care Provider.
  • Action: Refer the patient to a provider within their Managed Care network, as Medicare will not cover the services of providers outside this network.
• CO-201: The member's plan does not cover this service.
  • Action: Check the patient's coverage details. If the service should be covered, resubmit the claim with additional information or discuss other payment options with the patient.
• CO-202: Non-covered personal comfort or convenience services.
  • Action: Services classified as for personal comfort or convenience are typically not covered. The patient may be responsible for these charges.
• CO-203: Non-covered duplicate radiology film.
  • Action: Duplicate films are not typically covered. Check if the films were necessary and if so, appeal with supporting documentation.
• CO-204: Drug was not FDA-approved for medical condition.
  • Action: Verify the usage of the drug. If it was indeed used for an FDA-approved condition, resubmit the claim with supporting documentation.
• CO-205: Procedure code was invalid on the date of service.
  • Action: Confirm the procedure code and the date of service. If the procedure code was invalid on that date, you may need to correct and resubmit the claim.
• CO-206: National Provider Identifier (NPI) mismatch.
  • Action: Verify the NPI on the claim. If there's an error, correct it and resubmit the claim.
• CO-207: Revenue code is invalid on the date of service.
  • Action: Confirm the revenue code and the date of service. If the revenue code was invalid on that date, you may need to correct and resubmit the claim.
• CO-208: National Drug Code (NDC) invalid on the date of service.
  • Action: Confirm the NDC and the date of service. If the NDC was invalid on that date, you may need to correct and resubmit the claim.
• CO-209: Provider Tax ID/NPI combination is invalid.
  • Action: Verify the Tax ID and NPI on the claim. If there's an error, correct it and resubmit the claim.​  
• CO-210: Payment adjusted because pre-certification/authorization not received in a timely fashion.
  • Action: Ensure that pre-certification or authorization is received before the service is provided. If it was received in a timely manner, resubmit the claim with proof.
• CO-211: National Drug Codes (NDC) not eligible for rebate, are not covered.
  • Action: Check the patient's coverage details. The patient may be responsible for these charges.
• CO-212: Payment adjusted as the service/procedure is not paid separately. It is bundled into another service/procedure provided on the same day.
  • Action: No action required, as these services are typically bundled into another, more comprehensive service.
• CO-213: The Medical Review department determined that the service(s) is/are not medically necessary based on the information provided.
  • Action: If you believe the service was medically necessary, you may need to provide additional documentation and appeal the decision.
• CO-214: Workers Compensation claim is under review.
  • Action: Wait for the review process to be completed. There is no immediate action needed.
• CO-215: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.
  • Action: No immediate action needed. Wait for the separate notice for the other services.
• CO-216: Payment denied because service/procedure is not authorized in this region or by this payer.
  • Action: Verify the service and the payer. If an error was made, correct it and resubmit the claim.
• CO-217: Payment adjusted because patient has not met the required eligibility, spend down, waiting, or residency requirements.
  • Action: Verify the patient's eligibility and other requirements. If the patient meets the requirements, resubmit the claim with proof.
• CO-218: Payment adjusted due to a qualifying condition related to an Emergency Medical Treatment and Labor Act (EMTALA) violation.
  • Action: Review the specifics of the claim and the EMTALA violation. You may need to provide additional documentation and appeal the decision.
• CO-219: Reserved for national assignment.
• CO-220: The applicable fee schedule/facility-specific Medicare allowable amount for this procedure code at this place of service has not yet been determined by Medicare.
  • Action: Await determination by Medicare. There is no immediate action needed.
• CO-221: National Drug Code (NDC) is not payable under Part B Drug Competitive Acquisition Program (CAP) or is not a valid for Medicare Part B.
  • Action: Confirm if the drug falls under Part B Drug CAP. If it does, recheck the NDC and resubmit the claim.
• CO-222: Payment adjusted as the service was provided as part of a clinical trial.
  • Action: No immediate action needed. Clinical trial services may have different coverage rules.
• CO-223: Adjustment code for mandated federal, state, or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
  • Action: Check the specific mandate and adjust the claim accordingly before resubmitting.
• CO-224: Patient diagnosis for this service line is missing or invalid.
  • Action: Verify the diagnosis code and correct it if necessary, then resubmit the claim.
• CO-225: The new patient qualifications were not met.
  • Action: Review the qualifications for a new patient according to Medicare's guidelines. If the patient does meet these qualifications, you may need to provide additional documentation and appeal the decision.
• CO-226: Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete.
  • Action: Provide the necessary information and resubmit the claim.
• CO-227: Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete.
  • Action: Request the necessary information from the patient and resubmit the claim.
• CO-228: The operating Physician ID Number is missing, incomplete, or invalid.
  • Action: Verify the operating physician's ID number, correct it if necessary, and resubmit the claim.
• CO-229: The attending physician ID number is missing, incomplete, or invalid.
  • Action: Verify the attending physician's ID number, correct it if necessary, and resubmit the claim
• CO-230: The Referring Provider ID Number is missing, incomplete, or invalid.
  • Action: Verify the referring physician's ID number, correct it if necessary, and resubmit the claim.
• CO-231: The Billing Provider's State License Number is missing, incomplete, or invalid.
  • Action: Verify the billing provider's State License Number, correct it if necessary, and resubmit the claim.
• CO-232: The Prior Authorization (PA) number is missing, incomplete, or invalid.
  • Action: Verify the PA number, correct it if necessary, and resubmit the claim.
• CO-233: Services/charges exceed our coverage limits.
  • Action: Verify the services provided and the coverage limit of the patient's policy. If the claim exceeds the limit, the patient may be responsible for the additional amount.
• CO-234: This procedure is not paid separately.
  • Action: No action is required. This code means the procedure in question is bundled into another service or procedure and does not have a separate payment.
• CO-235: This service/procedure requires that a qualifying service/procedure be received and covered.
  • Action: Check if a qualifying service was received and covered. If so, resubmit the claim. If not, the patient may be responsible for the cost.
• CO-236: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative.
  • Action: Review the claim for any coding errors and correct as necessary. Check the National Correct Coding Initiative for proper coding combinations.
• CO-237: Legislated/Regulatory Penalty.
  • Action: This indicates that the claim adjustment is the result of a penalty as stipulated by law or regulation. No specific action may be applicable.
• CO-238: Claim spans eligible and non-eligible period of coverage.
  • Action: Separate the claim into two parts, one for the eligible period and one for the non-eligible period, then resubmit.
• CO-239: Claim lacks individual lab codes included in the test.
  • Action: Ensure all individual lab codes are included and resubmit the claim.
• CO-240: The diagnosis is inconsistent with the procedure.
  • Action: Verify the diagnosis and procedure codes. If necessary, correct the codes and resubmit the claim.
• CO-241: The date of service is inconsistent with the patient's age.
  • Action: Verify the patient's date of birth and the date of service. If necessary, correct the information and resubmit the claim.
• CO-242: The date of service is inconsistent with the patient's gender.
  • Action: Verify the patient's gender and the service provided. If necessary, correct the information and resubmit the claim.
• CO-243: The services billed are not covered due to the patient's end-stage renal disease (ESRD) entitlement.
  • Action: Check the patient's ESRD entitlement status and resubmit the claim with the necessary documentation.
• CO-244: The service is not covered under the patient's current benefit plan.
  • Action: Check the patient's benefit plan and resubmit the claim with the necessary documentation or discuss alternative payment options with the patient.
• CO-245: The hospital must file the Medicare claim for this inpatient non-physician service.
  • Action: The hospital should submit the claim instead of the individual non-physician provider. Ensure the correct entity is submitting the claim.
• CO-246: This non-payable code is for required reporting only.
  • Action: No action is required. This code is for reporting purposes only and does not affect the payment of the claim.
• CO-247: The subsequent care claim overlaps the global period of a previously submitted claim.
  • Action: Review the global period for the previously submitted claim. If the dates do not overlap, resubmit the claim with the correct dates.
• CO-248: The number of Coinsurance Days has been exhausted.
  • Action: Verify the number of coinsurance days for the patient. The patient may be responsible for additional costs if the coinsurance days have been exhausted.
• CO-249: The requested service is not a covered benefit under this demonstration project.
  • Action: No action is required. This code indicates that the service is not covered under a specific demonstration project.
• CO-250: The claim was received after the filing time limit.
  • Action: Check the date the claim was submitted. If it was filed late, you may not be able to resubmit. Be sure to submit all future claims within the filing time limit.
• CO-251: The attachment or other documentation was not received or was not received timely.
  • Action: Resubmit the claim with the necessary attachments or documentation.
•  CO-252 : An attachment or other documentation is required to adjudicate this claim.
  • Action: Resubmit the claim with the necessary attachments or documentation.
• CO-253: The physician or other provider was not certified/eligible to be paid for this procedure or treatment on the date of service.
  • Action: Check the provider's certification status on the date of service. If there is an error, correct it and resubmit the claim.
• CO-254: The care provided was outside the United States or as a result of war.
  • Action: No action is required. Medicare generally does not cover services provided outside of the United States or as a result of war.
• CO-255: The billed service is not covered by the payer.
  • Action: Check the patient's coverage details. If the service should be covered, resubmit the claim with additional information or discuss other payment options with the patient.
• CO-256: The patient is responsible for the services because they were not authorized.
  • Action: Check if prior authorization was required for the service. If it was, and you did not get it, the patient may be responsible for the costs.
• CO-257: The patient is over the plan's maximum benefit for the service.
  • Action: Check the patient's coverage details. If the maximum benefit has been reached, the patient may be responsible for additional costs.
• CO-258: The service is not payable per your contractual agreement or fee schedule with the payer.
  • Action: Check your agreement or fee schedule with the payer. If the service is indeed not payable, no further action is needed.
• CO-259: The claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable.
  • Action: Check the claim for errors and correct them. You may need to resubmit the claim.

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Learn how to effectively appeal a medical prior authorization denial with our comprehensive guide, including tips, templates, and resources to navigate the process with ease.

Are you struggling with a medical prior authorization denial? You're not alone. Many healthcare providers and patients find themselves in this frustrating situation. But don't lose hope! Our step-by-step guide will help you effectively appeal the denial and improve your chances of getting the necessary treatment or service authorized.

At GoHealthcare Practice Solutions, we specialize in simplifying the complex world of medical billing and prior authorizations. Visit our website at https://www.gohealthcarellc.com for more information on our services.

Step 1: Understand the Denial Reason
Before you can appeal a denial, you need to understand why it was denied. The denial letter should clearly state the reason, which may include lack of medical necessity, incorrect or incomplete information, or procedural errors. If the reason is unclear, contact the insurance company for clarification.

Step 2: Gather Supporting Documentation
To build a strong appeal, gather all relevant medical records, clinical notes, and any additional supporting documents. This may include:

• Diagnostic test results
• Treatment plans
• Progress notes
• Letters of medical necessity from your healthcare provider
• Peer-reviewed studies supporting the treatment

Step 3: Write a Clear and Concise Appeal Letter
Compose an appeal letter that clearly explains the reason for the appeal, why the service or treatment is medically necessary, and how it aligns with the patient's health plan benefits. Use persuasive language and be sure to reference any supporting documentation.

Step 4: Submit the Appeal
Follow the insurance company's guidelines for submitting the appeal, which should be detailed in the denial letter. This may include submission via mail, fax, or an online portal. Make sure to keep copies of all documents and confirm receipt of your appeal.

Step 5: Follow Up
Regularly follow up with the insurance company to check on the status of your appeal. Be prepared to provide additional information or clarification if requested.

Step 6: Escalate if Necessary
If the initial appeal is denied, consider escalating the case to an external review, if applicable. This process may involve an independent third-party reviewer who will examine the case and make a determination.

Step 7: Seek Professional Assistance
If you're still having difficulty with the appeal process or simply need guidance, consider seeking professional assistance from a medical billing specialist or a healthcare advocate. GoHealthcare Practice Solutions offers expert services to help healthcare providers navigate the complex world of medical billing and prior authorizations.​

While appealing a medical prior authorization denial can be challenging, following this step-by-step guide can improve your chances of success. Always remember to be persistent, keep accurate records, and don't hesitate to seek professional help if needed.

Discover the best medical practice management software in 2023 that can help streamline your healthcare facility's operations and improve patient care with advanced features and user-friendly interfaces.

As medical practices continue to embrace technology to improve their operations and patient care, the demand for effective medical practice management software (MPM) has skyrocketed. In this blog post, we'll explore the top 10 MPM software solutions that are transforming healthcare facilities in 2023.

Kareo(https://www.kareo.com)
Kareo is a comprehensive and user-friendly MPM software designed for independent practices. With features such as billing, scheduling, and electronic health records (EHR) integration, Kareo streamlines your administrative tasks and enhances patient care.

AdvancedMD (https://www.advancedmd.com)
AdvancedMD is an all-in-one MPM software that offers robust EHR and practice management solutions. Its automation and reporting features simplify administrative tasks, allowing healthcare providers to focus on patient care.

athenahealth (https://www.athenahealth.com)athenahealth is a cloud-based MPM software that offers a full suite of services, including EHR, billing, and patient engagement. Its intuitive interface and data-driven insights make it a top choice for healthcare facilities of all sizes.

DrChrono (https://www.drchrono.com)
DrChrono is an innovative MPM software that offers flexible, customizable solutions for EHR, medical billing, and practice management. With its mobile-first approach, DrChrono allows providers to manage their practice on the go.

CareCloud (https://www.carecloud.com)
CareCloud offers a user-friendly, cloud-based MPM software that helps practices improve efficiency, increase revenue, and enhance the patient experience. Its advanced analytics and reporting tools provide valuable insights for practice growth.

Greenway Health (https://www.greenwayhealth.com)
Greenway Health is a comprehensive MPM software that offers an integrated EHR, billing, and practice management solution. Its user-friendly interface and customizable features make it suitable for practices of all sizes.

eClinicalWorks (https://www.eclinicalworks.com)
eClinicalWorks provides a robust MPM software that offers EHR, practice management, and billing solutions. Its cutting-edge technology and telehealth capabilities make it a popular choice for modern healthcare practices.

NextGen Healthcare (https://www.nextgen.com)
NextGen Healthcare offers a powerful MPM software with integrated EHR, practice management, and billing solutions. Its wide range of features and scalable options cater to practices of all sizes and specialties.

Practice Fusion (https://www.practicefusion.com)Practice Fusion is a cloud-based MPM software that provides EHR, practice management, and billing solutions in one platform. Its intuitive design and affordable pricing make it an excellent option for small to medium-sized practices.

PrognoCIS (https://www.prognocis.com)
PrognoCIS is a customizable MPM software that offers EHR, billing, and practice management solutions. Its seamless integration and advanced features make it a reliable choice for healthcare facilities looking to improve their operations.

​In conclusion, medical practice management software has become an essential tool for healthcare facilities looking to streamline their operations and improve patient care. By exploring the top 10 MPM software solutions mentioned above, you can find the perfect fit for your practice and take your facility to new heights.

​Learn the top 10 tips to expedite the medical prior authorization process for healthcare providers, boosting efficiency and patient satisfaction.

Medical prior authorization can be a time-consuming and challenging process for healthcare providers. To help you expedite this process and improve your practice's efficiency, we've compiled a list of 10 actionable tips. Implement these strategies to streamline your medical prior authorization process and provide better care to your patients.

1. Implement a dedicated prior authorization team: Assign dedicated personnel to manage all aspects of the medical prior authorization process, ensuring that they have the necessary knowledge and training to handle all tasks efficiently.
2. Stay up-to-date on payer requirements: Payer requirements for medical prior authorization can change frequently. Keep up with these changes by regularly reviewing payer websites, newsletters, and communications.
3. Standardize your documentation: Establish a standardized method of collecting and documenting patient information to minimize errors and improve the consistency of your medical prior authorization submissions.
4. Use electronic prior authorization (ePA) solutions: ePA solutions can streamline the medical prior authorization process by automating tasks and reducing paperwork. Utilize these technologies to save time and improve accuracy.
5. Opt for multi-payer portals: Using multi-payer portals can simplify the submission process by allowing you to submit authorization requests to multiple payers through a single platform.
6. Establish clear communication channels: Effective communication between your staff, payers, and patients is crucial for a successful medical prior authorization process. Make sure you establish clear lines of communication to minimize delays and misunderstandings.
7. Track and analyze your prior authorization data: Regularly review your medical prior authorization data to identify trends, bottlenecks, and areas for improvement. This will help you make informed decisions and optimize your process.
8. Maintain a strong relationship with payers: Build and maintain strong relationships with payer representatives to facilitate open communication and ensure a smoother medical prior authorization process.
9. Educate patients about the prior authorization process: Make sure your patients understand the medical prior authorization process and their role in it. This will help them be more prepared and engaged, leading to better outcomes.
10. Partner with a medical prior authorization expert: Consider partnering with a company like GoHealthcare Practice Solutions (https://www.gohealthcarellc.com) to manage your medical prior authorization process. This will allow you to focus on patient care while experts handle the administrative tasks.

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By implementing these tips, healthcare providers can expedite the medical prior authorization process, improve patient satisfaction, and boost practice efficiency.

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Discover how healthcare data analytics can help medical professionals make informed decisions and improve patient care. Learn the benefits and best practices of data analysis in the healthcare industry.

Healthcare data analytics is a growing field that uses data analysis and insights to improve patient care and medical practice management. In today's data-driven world, it's more important than ever for healthcare providers to leverage data to make informed decisions and improve patient outcomes. In this article, we will explore the benefits and best practices of healthcare data analytics.

Benefits of Healthcare Data Analytics

• Improved Patient Outcomes:

By analyzing patient data, healthcare providers can identify patterns, risks, and opportunities for intervention. This can lead to more accurate diagnoses, better treatment plans, and improved patient outcomes.

• Cost Reduction:

Healthcare data analytics can help identify inefficiencies in medical practice management, reducing unnecessary costs and improving revenue cycle management.

• Better Resource Utilization:

By analyzing data on patient demographics, medical history, and treatment outcomes, healthcare providers can optimize resource utilization, such as staff and equipment, to improve patient care.
Enhanced Risk Management:
​Data analytics can help identify and mitigate risks, such as medical errors, adverse events, and fraud, leading to improved patient safety.

​Best Practices for Healthcare Data Analytics

• Collect Relevant Data: 

To obtain meaningful insights, healthcare providers need to collect and store relevant data. This includes patient demographics, medical history, treatment plans, and outcomes.

• ​​Use the Right Tools: 

Healthcare providers need the right tools and technologies to analyze and visualize data. These may include electronic health records (EHRs), business intelligence software, and data visualization tools.

• Ensure Data Security and Privacy: 

Healthcare data is sensitive and needs to be protected from unauthorized access. Healthcare providers must implement data security and privacy measures, such as encryption, access controls, and auditing.

• Collaborate and Share Insights: 

Healthcare providers can benefit from sharing insights and collaborating with other medical professionals. This can lead to improved decision-making and patient care.

Healthcare data analytics has the potential to transform the healthcare industry by improving patient care, reducing costs, and enhancing resource utilization. By following best practices and using the right tools, healthcare providers can unlock insights from their data and make informed decisions.

Test Your Survey Before Launching
Before distributing your survey to patients, test it on a small group of people to ensure that the questions are clear, unbiased, and easy to understand. This will help you make any necessary adjustments before launching the survey.

Distribute Surveys Through Multiple Channels
To increase response rates, distribute your survey through multiple channels, such as email, text message, and in-person. This will make it more accessible and convenient for patients to provide their feedback.

Monitor and Analyze the Results
Regularly monitor the results of your patient satisfaction surveys and analyze the data to identify trends and areas for improvement. Use the insights gained from the survey results to make informed decisions about enhancing patient care.

Act on the Feedback
After analyzing the results of your survey, take appropriate action to address any areas of concern. Communicate these changes to your patients to show that you value their feedback and are committed to improving their experience.

Conduct Regular Surveys
Patient satisfaction surveys should be an ongoing process. Conduct surveys regularly to track your progress and continue making improvements based on patient feedback.

Patient satisfaction surveys are a vital component of any successful medical practice. By following these top 10 tips, you'll be well on your way to mastering patient satisfaction surveys and enhancing patient care.

References and Sources:

1. Agency for Healthcare Research and Quality. (2021). CAHPS: Surveys and Tools to Advance Patient-Centered Care. Retrieved from https://www.ahrq.gov/cahps/index.html​​

Learn how to effectively appeal a medical prior authorization denial as a medical provider with this comprehensive guide. Discover helpful tips and strategies to increase your chances of success. GoHealthcare Practice Solutions can also assist you in navigating the process.

As a medical provider, dealing with medical prior authorization denials can be frustrating and time-consuming. However, appealing these denials is a necessary process to ensure that your patients receive the care they need. In this comprehensive guide, we will discuss the steps you can take to appeal a medical prior authorization denial effectively. We will provide you with practical tips and strategies to help you navigate the process with confidence.

Step 1: Understand the Reason for Denial
The first step in appealing a medical prior authorization denial is to understand the reason for the denial. Review the denial letter carefully, paying attention to the specific reason(s) for the denial. This will help you to identify the specific information or documentation needed to support your appeal.

Step 2: Gather Supporting Documentation
Gathering all necessary supporting documentation is crucial in the appeal process. This includes medical records, test results, and any other relevant documentation that supports the medical necessity of the procedure or treatment. Make sure to also include any additional information that was not submitted with the original prior authorization request.

Step 3: Prepare a Strong Appeal Letter
Crafting a compelling and well-organized appeal letter is essential in appealing a medical prior authorization denial. The appeal letter should be concise and to the point, highlighting the medical necessity of the procedure or treatment and providing evidence to support your case. It should also address the specific reason(s) for the denial and explain why the denial was incorrect.

Step 4: Submit the Appeal
Once you have prepared your appeal letter and gathered all necessary supporting documentation, submit your appeal according to the insurer's guidelines. Make sure to follow all submission requirements, including deadlines and required forms. You may also consider submitting the appeal via certified mail or fax to ensure that it is received.

Step 5: Follow Up and Be Persistent
Following up on your appeal and being persistent is crucial in ensuring a positive outcome. Keep track of all communication with the insurer and follow up regularly to ensure that your appeal is being processed. Be persistent in advocating for your patient's care and do not be afraid to escalate your appeal to a higher authority if necessary.​

Successfully appealing a medical prior authorization denial requires persistence, attention to detail, and an understanding of the appeal process. By following the steps outlined in this guide and seeking assistance from GoHealthcare Practice Solutions, you can increase your chances of a positive outcome for your patient's care. Remember, advocating for your patient's health is always worth the effort.

Develop a Strong Company Culture
Foster a positive work environment by prioritizing employee wellness, promoting open communication, and recognizing the hard work of your team. A strong company culture attracts and retains top talent.

Create a Comprehensive Onboarding Process
A well-designed onboarding program helps new hires feel supported and prepared for their roles. This leads to improved job satisfaction and retention rates.

Optimize the Interview Process
Streamline your interview process by creating a structured system to evaluate candidates. This ensures you hire the right individuals for your practice and minimizes the risk of costly hiring mistakes.
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Invest in Ongoing Staff Training
Continuing education and professional development opportunities keep your team up to date with the latest medical advancements and best practices, ensuring your practice remains competitive.

Monitor Performance Metrics and Conduct Regular Reviews
Track key performance indicators (KPIs) and conduct regular performance reviews to assess your team's strengths and weaknesses. This helps identify areas for improvement and growth, ensuring your medical practice continues to thrive.

Effective medical practice staffing solutions are vital for providing the highest quality patient care. By implementing these top 10 strategies, you can optimize your workforce, improve employee satisfaction, and ensure your medical practice's ongoing success. Keep in mind that the key to successful staffing lies in a combination of proactive planning, strategic partnerships, and continuous improvement. Invest in your team and watch your medical practice flourish.​
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​Patient engagement is critical for improving outcomes and building a successful medical practice. By implementing the strategies outlined above, you can engage your patients, improve their satisfaction, and ultimately enhance their health outcomes. Remember, patient engagement is an ongoing process, and it requires a commitment to continuous improvement and a patient-centered approach to care.

References:

1. O’Connor, S., & Hanlon, P. (2018). Examining the effectiveness of mHealth interventions for patients with diabetes. Journal of Diabetes Nursing, 22(2), 51-56.
2. Chen, J., Cade, J. E., Allman-Farinelli, M., & Greenwood, D. C. (2017). The most popular smartphone apps for weight loss: a quality assessment. JMIR mHealth and uHealth, 5(3), e33.
3. Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2), 207-214.
4. Hardee, S. G., Osborne, A., Steigerwald, M., & Combs, B. (2019). Patient satisfaction with telemedicine encounters in an outpatient pulmonary practice. Telemedicine and e-Health, 25(3), 199-204.
5. Oshima Lee, E., Emanuel, E. J., & Emanuel, L. L. (2013). Patient engagement in digital health. JAMA, 310(20), 2031-2032.

Discover how outsourcing medical billing and coding services can streamline your practice's operations and boost revenue. Learn about the benefits of entrusting these critical tasks to experienced professionals.

Medical billing and coding are integral components of any medical practice. Ensuring that claims are accurately coded and submitted on time can make the difference between a thriving practice and one struggling to keep the lights on. But with the complexity of today's healthcare system and the sheer volume of claims to process, many practices are turning to outsourcing as a solution. In this post, we explore the benefits of outsourcing medical billing and coding services and how it can help your practice achieve maximum revenue and efficiency.

1. Cost savings: Outsourcing medical billing and coding can help practices reduce costs associated with hiring and training in-house staff. It can also eliminate the need for expensive software and equipment.
2. Increased revenue: Outsourcing ensures that claims are accurately coded and submitted in a timely manner, resulting in fewer denials and increased revenue for the practice. This can also improve cash flow and reduce the time it takes to get paid.
3. Expertise: Professional medical billing and coding services have trained experts who specialize in this field. They stay up-to-date with the latest industry changes, regulations, and guidelines, ensuring that your practice is always compliant.
4. Improved efficiency: Outsourcing can streamline your practice's operations by eliminating the need to manage and train billing and coding staff. This can free up your time to focus on patient care and other important aspects of your practice.
5. Scalability: As your practice grows, outsourcing medical billing and coding can easily scale to meet your needs. This can help you avoid the need to continually hire and train new staff as your patient volume increases.

Outsourcing medical billing and coding services can provide numerous benefits for medical practices. From cost savings and increased revenue to improved efficiency and scalability, entrusting these critical tasks to experienced professionals can help your practice thrive. To learn more about outsourcing medical billing and coding services, contact a trusted provider in your area.
​
Sources:

• "Outsourcing Medical Billing and Coding: Pros and Cons" by Joe Hargett, Physicians Practice
• "The Benefits of Outsourcing Medical Billing and Coding" by John Lynch, Practice Builders
• "Outsourcing Medical Billing and Coding: 5 Key Benefits" by P.J. Cloud-Moulds, Kareo
• "Why You Should Consider Outsourcing Your Medical Billing" by Kristin Lewotsky, Medical Economics.

​Mastering Medicare Compliance: Navigating the Recovery Audit Contractor (RAC) Program for Accurate Healthcare Claims

Explore the Recovery Audit Contractor (RAC) program, responsible for identifying and recovering improper Medicare payments in healthcare claims. Learn about the RAC process, types of improper payments, provider appeals, education initiatives, and key aspects of the program to ensure compliance and maintain Medicare integrity.

Recovery Audit Contractors (RACs) are private companies contracted by the Centers for Medicare & Medicaid Services (CMS) to identify and correct improper Medicare payments. Their primary role is to review post-payment healthcare claims submitted by healthcare providers and identify any discrepancies or errors that may have led to overpayments or underpayments.

RAC Program Objective
The RAC program was established in response to the Medicare Modernization Act of 2003 and the Tax Relief and Health Care Act of 2006. The primary objective of the program is to ensure the integrity of the Medicare system by identifying and recovering improper payments, while also preventing future errors through provider education.

RAC Process
RACs utilize a combination of automated and manual review processes to examine healthcare claims. They review claims to identify potential errors, such as incorrect billing codes, duplicate payments, non-covered services, or incorrect payment amounts.

a) Automated Review: RACs use software algorithms to identify billing patterns and potential errors. This process can identify high-risk claims without human intervention.

b) Manual Review: When the automated review identifies a potential error or when the claim is complex, RACs perform a manual review. This involves a detailed examination of the medical record and supporting documentation by a certified medical professional.

Types of Improper Payments
RACs primarily focus on identifying four types of improper payments:
a) Overpayments: When a healthcare provider receives more reimbursement than they are entitled to for a service.
b) Underpayments: When a healthcare provider receives less reimbursement than they are entitled to for a service.
c) Non-covered Services: When a healthcare provider receives reimbursement for a service that is not covered by Medicare.
d) Incorrectly Coded Services: When a healthcare provider receives reimbursement for a service based on an incorrect billing code.

Provider Appeals Process
Healthcare providers have the right to appeal RAC determinations. The appeals process consists of five levels, allowing providers multiple opportunities to contest the decision. RACs are required to provide detailed rationale for their decisions and return any funds collected if the appeal is successful.

Provider Education and Outreach
RACs are responsible for educating healthcare providers on proper billing practices to prevent future errors. This includes conducting outreach programs, providing educational materials, and offering webinars to ensure providers have the necessary resources to comply with Medicare billing rules.

Program Performance
The RAC program has been successful in recovering billions of dollars in improper payments since its inception. It has also led to significant improvements in billing practices, contributing to the overall integrity of the Medicare system.

In conclusion, Recovery Audit Contractors play a crucial role in ensuring the proper use of Medicare funds. By identifying and recovering improper payments and educating healthcare providers on correct billing practices, RACs help maintain the integrity of the Medicare system and safeguard its resources for future beneficiaries.

Here are some additional important aspects of the Recovery Audit Contractor (RAC) program:

Contingency Fee Structure: RACs are paid on a contingency fee basis, meaning they receive a percentage of the improper payments they recover. This fee structure incentivizes RACs to identify and recover as many improper payments as possible. However, some critics argue that this model may encourage RACs to be overly aggressive in their audits.

RAC Jurisdictions: The United States is divided into several RAC regions, with each RAC responsible for a specific jurisdiction. This regional approach allows RACs to focus on the unique healthcare landscapes and trends within their respective regions, enhancing their ability to identify and recover improper payments.

Look-Back Period: RACs typically review claims within a three-year look-back period, starting from the date of service. This means that healthcare providers should maintain accurate and complete records for at least three years to ensure they can adequately respond to any RAC audits.

RAC Validation Contractor (RVC): The RAC Validation Contractor is an independent entity contracted by CMS to oversee the RAC program's accuracy and effectiveness. The RVC conducts independent reviews of RAC determinations, ensuring that RACs are adhering to Medicare rules and regulations and maintaining a high level of accuracy.

Provider Compliance Group (PCG): The Provider Compliance Group is a CMS division responsible for coordinating all Medicare provider compliance efforts, including the RAC program. The PCG plays a crucial role in ensuring that the RAC program aligns with the overall goals and objectives of the Medicare system.

Limitations on RAC Audits: To minimize the administrative burden on healthcare providers, CMS has implemented some limitations on RAC audits. For instance, RACs are subject to a limit on the number of medical records they can request from a provider within a specified period. Additionally, RACs must complete their reviews within specified timeframes to minimize disruption to providers.

Continuous Program Improvement: CMS regularly evaluates and updates the RAC program to enhance its effectiveness, address stakeholder concerns, and adapt to the evolving healthcare landscape. This may include modifying audit methodologies, updating regulations, and refining the RAC program's focus areas.

By understanding these additional aspects of the RAC program, healthcare providers can better navigate the audit process and ensure compliance with Medicare billing rules and regulations.

Reading references related to the Recovery Audit Contractor (RAC) program:

Centers for Medicare & Medicaid Services. (2021). Recovery Audit Program. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program

Centers for Medicare & Medicaid Services. (2021). Recovery Audit Program – Provider Resources. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Provider-Resources

Department of Health and Human Services, Office of Inspector General. (2019). Medicare Recovery Audit Contractors and CMS’s Actions to Address Improper Payments, Referrals of Potential Fraud, and Performance. Retrieved from https://oig.hhs.gov/oas/reports/region4/41804058.asp

American Medical Association. (n.d.). Recovery Audit Contractors (RAC) audits. Retrieved from https://www.ama-assn.org/practice-management/medicare/recovery-audit-contractors-rac-audits

American Hospital Association. (n.d.). Recovery Audit Contractors (RACs). Retrieved from https://www.aha.org/issues/recovery-audit-contractors-racs

These references provide a comprehensive overview of the RAC program, its objectives, processes, and impact on healthcare claims, as well as insights into the program's performance and related concerns.

​Limitations of Telemedicine Services:
While telemedicine services have many advantages, there are also some limitations to consider. In this section, we will explore the challenges faced by medical professionals when using telemedicine services, including issues with insurance reimbursement and technological barriers.

Best Practices for Telemedicine Services:
To make the most of telemedicine services, it is important to understand best practices for their use. We will discuss strategies for selecting a telemedicine provider, preparing for a telemedicine visit, and ensuring privacy and security during remote consultations.

Telemedicine services offer numerous benefits to patients and medical professionals alike. By providing remote access to medical care, telemedicine services are improving healthcare outcomes and reducing costs. As the world continues to adapt to new norms, telemedicine services are becoming increasingly popular. With this comprehensive guide, patients and medical professionals can understand how to utilize telemedicine services to their fullest potential.