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Category Archives: Medical Billing News

2018 MACRA Update for Small Practices

CMS released rule for quality Payment Program 2018. As we are moving toward the end of 2017, let’s have a look at the rule proposed for next year.


2018 MACRA Update for Small Practices


Here are some of the points that summarize the proposal.


QPP is Growing

The new proposal comes with significant changes yet most of the rules have remained same. Some of the core program elements like performance categories, the structure of program tracks are still unchanged.

What does this mean for small healthcare practice? MIPS has a definite accelerating path. This is the best time to get comfortable with this program.


Excluding Cost Category

CMS proposed that the cost category will only account for 0% of the performance score and will not impact payments. Even though it is not the final rule but it is in momentum. CMS is asking for feedback prior to publishing this final rule.

This category weights will remain same in 2018 as it was in 2017 with 60% counting for quality, 25% for Advancing Care Information and 15% for Improved Activities.

This means it’s a good idea to understand and analyze the process and data as cost inclusion is expected to become a composite Performance Score.


More Flexibility

CMS has proposed to enhance the planned thresholds for low volume exclusions. In 2017, clinicians or groups having $30,000 or more in Part B were allowed charges of 100 or more in Part B beneficiaries. In 2018, CMS is offering threshold of 90,000 or more in Part B, which allows charges of 200 in Part B beneficiaries.


This means low volume Medicare Part B practice might be excluded in 2018 to a larger extent. Every low volume practices should verify their Medicare Part B metrics to know their status.


Bonus Points

CMS proposed adding bonus points to reward clinicians and increase flexibility for groups that face difficulty in scoring well.

  • Around 10 percentage points are available for improvement in performance in quality category. This bonus depends on improvement rate in quality category score between 2017 and 2018 performance year.
  • The bonus of 3 points is given for eligible clinicians dependent on patient medical complexity. This assessment is based on the average Hierarchical Conditions Category risk score.
  • 5 points bonus to eligible group or clinicians having a small practice with fever facility.

Small practice can score bonus points to counterbalance their small size and complex patient population.


The above-discussed points will help you in preparing for the new MACRA updates. These points will help you in having a thriving revenue cycle. You can even hire medical coding and billing to maintain revenue cycle management and focus on quality care.

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Why is it a good time to outsource your Medical Billing Practice

More and more physicians are going for outsourcing their medical billing requirements. As per a recently released survey by Grand View Research, this growing demand will result in a rapid increase of medical billing outsourcing market. This means, it will surpass the demand of in-house billing.


Why is it a good time to outsource your Medical Billing Practice


This information somewhat echoes research conducted in 2014 that found that 90% small and independent physicians were thinking to outsource their billing needs.

Below are the reasons why physicians are moving from in-house to outsourcing their billing needs. These reason gives you perfect justification to follow the same practice.


Reasons for Increase in Demand

The healthcare industry is facing several changes over the past year. Right from the introduction of Affordable Care Act to ICD-10, physicians are finding it extremely difficult to stay up with these new regulations. Below are the reasons why physicians are turning toward outsourcing option.


  1. Limited in-house Expertise

Coding, billing and revenue cycle management has become more complex than ever before. This now requires greater expertise level to achieve optimal cash flow and maximum reimbursement.

Indeed, in-house coders and biller may process many claims each month but a medical billing company processes thousands of claims across various specialties. Physicians can reap immense benefits from their wider range of knowledge and expertise.


  1. Obsolete Software

Well, billing software has been going under serious transformation to meet the latest demand of the industry. Upgrading software becomes crucial to maintain billing efficiency and stay compliant. And upgrading software can cost you around ten thousand dollars. Most of the physicians are reluctant to invest this much and find their current software obsolete. This makes their billing process less efficient and difficult.


  1. Prime Focus on Patient Care

With changes like MACRA and transformation to value-based care, physicians have to focus on quality metrics to stay away from penalties. By outsourcing their billing needs, physicians can focus on quality care without any added stress.


When Outsourcing Makes Sense

Indeed, outsourcing your medical billing need is a tough decision. Making a switch becomes daunting and intimidating tasks. But it is actually a smooth process. Always remember, every medical billing company is not same. In case you face a bad experience, don’t just settle down. Start searching for a medical billing company that is responsive and can meet your need.


While budget and pricing is a crucial part of the discussion but refrain from making these factors as the ultimate deciding factors. Paying lower fees to any company who don’t properly collect your reimbursement is not the type of bargain you are searching for.

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Why reviewing your medical Practice’s AR Aging reports is important

Well, it obvious that medical practitioners know the importance of denied claims and know your billing team are maintaining follow up chain. One crucial element to address is whether you have arranged your AR into bucket on the basis of unpaid days.

Why reviewing your medical Practice’s AR Aging reports is important

Are you reviewing medical practice AR aging report? A detailed AR report that has separate key segments like denial pattern, claims denied and payer specific  will help you deal with backlogged revenue productivity.

For a detailed insight on aging AR, you can divide the Accounts Receivable on the basis of CPT codes and insurance. Such reports will help you find the billing performing metrics and get in you in the loop with the performance of medical billing department.

Most physicians do not check the Aging report as it is assumed as a tedious task for the in-house account department. However, if you go to outsource your medical coding and billing task, the worries surrounding the reviews of AR aging report can be taken care off.

You can try the below discussed point to make working of the aging report easier:

Routinely working on report

Routinely working on aging report makes it easier and simple to work as the problem claims are taken care and missed claim are checked. This consistently eliminate the claims that are piled up on reports. You need to know that if you don’t adhere to work on claims report regularly then get ready for growing workload.

Always track the actions taken on Suspicious Claims

Keeping a track of points that seem suspicious can reduce the workload. You will only have to keep an eye on the verified claims.

Dispose the Uncollected Claims

Having claims that are not collectable come with an headache and also double up the work. For instance, if you have claims that has no justification for an appeal and you can’t even bill patient, then get the claim right out of the system.

Verify the Clearinghouse Reports

Usually the responses to why any calin is not paid are mentioned in the clearinghouse reports. If you will not verify these reports then the cases will remain outstanding with no clarification. When you will check the clearinghouse reports and will take appropriate action on problematic claims. You will discover that either these cases not be on aging report (As they would have been processed) or will have clarification as to why they are i report and any further activity is not required.

Get Enlisted with insurance provider’s website for status checks

Checking claims online is less demanding than a call. Enlisting medical billing website and insurance will make it less demanding to work the review the AR Aging report.  


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3 Crucial Things you Need to Know About Trump’s Execution Policy


In January 2017, Donald Trump signed execution policy against the ACA ( Affordable Care Act). ACA was most significant regulatory overhaul implemented by Obamacare. The execution order of president trump strives towards minimizing regulatory and economic burdens of ACA by replacement plan. It’s crucial to know the below discussed things prior to implementation of executive order.



  1. Execution is Limited

The execution plan offers broad guidance as it authorizes agencies and states to make changes on maximum extent permitted by the law. This helps agencies such as CMS Administration, Health and Human Services, Treasury, IRS, etc as it provides state with more controlled and flexibility for creating open and free healthcare market. Indeed, this is slightly limiting but nothing can be done till the time agency heads are not appointed.


  1. Interstate Insurance Market

Execution order strive towards creating interstate insurance market, allowing purchasing of health insurance across state lines by the individual. Though the insurance sale is allowed across state under ACA, Trump focuses on having replacement plan centred on patient along with improving healthcare.


  1. Cut Taxes

Some taxes under ACA can be undo such as tax on pharmaceutical companies and health insurance. The order encourages agencies to waive fee, taxes and penalties under ACA. According to Trump his team will come up with plan that are simple and offers wonderful solution to failed disasters i.e, ACA.


Staying aware of the new healthcare policies, information and legislative transformation prevents practices from being unaware or unprepared of the new healthcare reforms. Turning blind eye to these reforms can affect health care reimbursement immensely.

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Ways in which Medical Bills Affect your Reimbursement

Facing sky-high bills or mistakes and delay in the insurance processing? Introduction of new reforms causes havoc on medical billing. Even before ACA began into effect, bringing MACRA into picture added to the growing share of risk.




In the changing climate, physicians are striving towards managing revenue differently to ensure delivered value is paid appropriately in terms of timeliness and accuracy.


  • The financial side takes account receivable (A/R) into consideration and its metrics are around denial management, collection rates and denials.
  • The Technical side considers applications, systems and processes in the complete patient- provider interaction.
  • The operational side considers staffing, workflows and vendor relationship.  


Undoubtedly technology plays crucial role in improving reimbursement rates and claim management but can’t replace processes responsible for increasing or introducing errors that leave bills overpaid, unpaid and underpaid.


Healthcare organizations takes into consideration various components of patient providers fit to revenue cycle and introduce loopholes leading to risk and loss.

  • Pre -service which includes pre-authorization and pre-registration
  • Care Process
  • Billing Services (Collection, follow ups, customer support)
  • Process integrity practices (coding compliance, chargemaster, clinical documentation)
  • Administration Services (Fee schedules, Contract management, debt collections, denial management and, managed care contracts)


Whether you name it protecting reimbursement or revenue cycle, making improvement simultaneously can lead towards a success one.



Claim processing operation with well monitored process and skilled personnel. The revenue cycle is just a part of claims processing which varies according to makeup of healthcare organization.


After identifying the personnels responsible for claim processing, make sure that claim reimbursement improvements are addressed in timely manner, different department leaders must communicate in scheduled way with frequent meetings.


Financial counselors, business office manager and member’s authorization team can conduct meetings on biweekly basis to track trends in patient access. The business staff, group administrator and business office manager must conduct meetings on monthly basis to discuss cash balancing, underpayment trends and claim related concerns.


Irrespective of team size, key stakeholders and activities in claim process starting from front to back should be structured in standard way.



With the transition to pay-for -performance, healthcare organization has started considering that the impact of their clinical practices on the bottom lines as providers assume greater accountability.


Under this category the question falls into the following parts: patient-centred and regulation-based. The first one has become salient with Center for Medicare and Medicare services imposing more rules that is leading to increasing denial rates.


The clear winner of this game will be the ones who focuses on wants and needs of patients. As there is a transition from volume to value healthcare, investment on healthcare is becoming crucial. With patients becoming more alert with the offered healthcare, providers has to offer something worth paying for.




Regardless of health care size, organization finds themselves facing challenges in particular spot when getting reimbursed. This makes it important to see what practices are adopted by practice to succeed in reimbursement environments.


Not managing revenue cycle effectively can lead to rise in billing costs, dropping collection rates and increasing account receivables to a certain point where vale of acquisition is lost.


This understanding becomes immensely crucial during the time of increasing provider consolidation where big organizations are affiliating or acquiring with independent practices. Your revenue quality depends upon infrastructure, linkage of processes and people. There are various methods of billing model. Such as;


  • Centralized Billing Model

In this model, the majority functions takes place in central business office. This offers economies of scale, dedicated expertise, consistency, complete reporting and monitoring, while the disadvantages lies in increased physician billing, higher billing costa and response lag.  

  • Decentralized Billing Model

In decentralized Billing Model, majority of billing functions are managed at site of service. It even allows organizations to have close relationship with patients, site level control, create sense of ownership and prompt resolution to physician-driven errors. On the negative side, it creates disparate standards and staffing inefficiencies.


  • Outsourced Model

In this model, third party manages the functional areas to enable organization to focus on core competencies at the cost of third party.


Regardless of model you select, organization who successfully manage revenue cycle starting from pre-registration to zero balance are one who considers big picture and ability to communicate with staff whose performance affects reimbursement immensely.

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4 Facts that every physician should know about MACRA



  1. The Merit-Based Incentive Payment System determines the Medicare payment adjustments. There are four categories which contributes to annual MIPS final score.
  • Quality (60%)

Physicians have to report on more than 6 quality for minimum 90 days including outcome measure. Groups leveraging web interface have to report 15 quality measure in one complete year.

  • Advancing Care Information or Meaningful Use (25%)

In this participants have to meet the following requirements for minimum 90 days.

  • Security Risk Analysis
  • Provide Patient Access
  • Send Care Summary
  • Analysis Security Risk
  • E- Prescribing
  • Accept/ Request Care Summary
  • Select upto 9 measures for at least 90 days to get additional credit.


  • Clinical Practice Improvement Activities (15%)

Most participants have to complete four improvement activities within minimum of 90 days.

  • Cost Based Modifier

This will be calculated from adjudicated claims and will get weighed from 2018. The final score of the providers for an year is determined by MIPS payment adjustments. The final scores are released by CMS.


In order to qualify an advanced Alternative Payment Model, participants have to use Certified EHR technology and report quality measures that are evaluated under MIPS. All the eligible providers will then qualify for the following:

  • Annual 5% bonus payment beginning from 2019 through 2024.
  • Starting from 2026, there will be higher annual premiums for few providers
  • Physician-focused payment models to increase flexibility.

Cases where physicians will not send their data,  will receive 4% negative payment adjustment in the year 2019. This penalty will increase with growing years to 5% in 2020 and 9% in 2022.



CMS has reduced the cost and time to participate with the increase in availability of Advanced APMs especially for small healthcare providers. They are even providing $20 million in one year for technical support and outreach to these small practices for atleast next five years.

To keep it precise, the payment adjustment size depends on the data submitted and quality result. With growing complexities in getting reimbursements, healthcare providers are outsourcing their medical coding and billing requirements.

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How MACRA Affects Your Practice in 2017

An important role of the healthcare institutions is to provide quality health services to a diverse population. Besides, they also take care of the patient satisfaction, operating costs, medical outcomes, the requirements of the government mandates and regulatory compliances.


A big transformation in the medical sector came with the passing of MACRA or Medicare Access and Chip Reauthorization Act. It is a rather complex piece of legislation, but a beneficial one that will bring a new dawn in the clinical payment in the coming decades.


Understanding the basics of MACRA

MACRA is an outcome of CMS and HHS coming together to end the degraded practise of the Sustainable Growth Rate, to oversee any discrepancy in payments. MACRA holds within its jurisdiction the payment of the physicians based on the quality of the service by the largest healthcare insurer of the United States, CMS. Though the process will start from the 1st January, 2017, the reimbursement to the doctors will be from 2019.

But, if you think that 2019 is far away, think again! 2017 will be a crucial year for the medical billing sector as it will have a direct impact on the payment computation. Here, let us understand how will MACRA influence your practise in 2017. To put it in a very simple term, MACRA means paying the medical practitioners based on their quality service and the outcome, rather than on the volume. Under MACRA legislation, there are two modes of payments- The Merit Based Payment System (MIPS) and Alternative Payment Models (APM).


Impact of MACRA on your practise in 2017

The year 2017 will be  very crucial for the medical practitioners as it will set the base for reimbursement adjustments in 2019. The basic and notable upgrade of MACRA’s Quality Payment Program (QPP) is the transition from fee based on service to fee based on value. Due to this, the most visible impact will be a drastic change in clinical performances in 2017. The medical industry will witness the following impact in 2017.


MIPS and APM will be the two options for Medicare Provider Payment

MIPS is a combination of the PQRS, Value Modifier and EHR. Under MIPS, the eligible professionals like doctors, nurses, chiropractors, dieticians and all the professionals related to the medical industry will be measured on the following factors-

  • Quality
  • Proper use of certified EHR technology
  • Clinical practise improvement and
  • Proper resource use

The participants of the APM will receive a few beneficiaries. They will automatically reap the benefits of MIPS and additionally get anual 5% bonus payments from 2019-2024, will be entitled to more flexibility through physician focused payment models.


An increase in provider reimbursement

From 2019 to 2026, the rate for APM and MIPS will remain static, which will witness a rise annually from 2026. From 2026, the MIPS will increase by 0.25%, which is a downfall from the regular 0.50% annually. But, as far as APM is concerned, the annual payments will increase by 0.75%. All these have triggered a very crucial concern that it will become rather difficult, with such annual payment rates to keep up the pace with inflation.


Penalties will come in

High performing physicians will be entitled to bonuses, whereas the low performing ones will have to face penalties. If the MIPS scores goes down continuously for a physician, then the penalties will be 4 %, 5%, 7% in 2019, 2020 and 2021 respectively.


A direct impact on the physician practise FMV

Due to MACRA and the creation of two Medicare payment provider models, there will be a fair impact on the future physician practices. Physicians will now focus more on value based practice as the reimbursement will get shifted towards value based payments.

Therefore, MACRA will benefit the medical industry owing to the fact that it will put an end to the sustainable Growth Rate and improve the quality of the medical service. To all the low performing and corrupt practitioners, MACRA may seem a nightmare as it will impose penalties.

So, what you need to remember in 2017 is to improve the patient care service and take proper measures to implement financial strategies so that you can get proper reimbursement in 2019.

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3 Ways in Which Mobile Technology Can Guide Medical Practitioners


Starting from smartphones to tablets, mobile technology is becoming an integral part of the everyday life. Medical field is no exception. Mobile technology is one of the on job asset for medical professionals. In Fact, in the field of healthcare mobile app can cover a spectrum of requirements. Medical facilities can drive benefits by investing in mobile technology during their shifts.



Improve Communication

  • Time is one of the crucial aspect for medical industry. Physicians are responsible for several patients and there are situations when patients need services at once. In these scenarios, they have to equipped with devices that they can be leveraged to reduce the time consumed in attending one patient.
  • Healthcare information and Management System Society stated that around 52% of hospitals leverage mobile health technologies. With the growth in using mobile tech, they have witnessed an improved communication facility. An instant message can do the work as it can be helpful in tracking down your colleagues.
  • There is an improved communication between patients and providers with the introduction of mobile technology. According to HIMSS survey, approximately 58% medical professionals use patient portals on their mobile devices. This help them in having access to the medical records, send secure messages and refill the prescriptions using these portals.
  • Different departments are not required for attending phone calls meanwhile the coworkers are tracking down files. Physicians can find all the required information in one location whenever and wherever.

Eliminating Errors

  • Here is another good news! You can reduce errors to large extent by using digital communications. Only a single file can be created will for containing all the information regarding the patients and providers that can be instantly shared among others too. This is useful for those patients dealing with multiple care team, as this way they can eliminate errors. These errors possibly occurs because of the mismatched data through multiple copies.
  • These portals are accessible to patients which help in sending alert in the case where something looks amiss.
  • You can  further eliminate issues that are related with handwriting as online messages consistently legible to decrease the chances of misreading the notes.
  • Any slightest loophole in the communication can result in disastrous situation in medical healthcare. Mobile technology provides you with instant and clear information which help in rendering quality care.

More Efficiency

The leverage of using mobile technology whenever and wherever can save considerable amount of time. This time can be dedicated to other important tasks. In a recent study conducted by Ricoh, hospitals using smartphones, tablets and other mobile tech are 74% more efficient than those you maintain distance from it.

By leveraging technology in the following manner you can have a quality care service and an effective revenue cycle. In the current scenario, it’s important to remain updated. The healthcare industry changing at a rapid speed and many healthcare practitioners are even hiring medical coding and billing company to stay in touch with the changes.

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Your Top 3 Rights As a Patient


It very crucial to know about your rights regarding your care and planning ahead whether these rights are exercised in the favour or not? Usually, people gets carried away in the horror of the moment and gets agreed to whatever is said by the physician. Keep in mind that your treatment is finally your decision. There are many hard decision that you have to make when it comes to healthcare. Physician’s role is to supply you with information and rest depends on you.


Your top 3 rights of as a patient are as following:


These rights includes treatments that you are willing to refuse or consent. There are only two cases where treatment can begin without your consent. These two cases are:

  • Medical emergency
  • Well being is threatened and you can’t explicitly forbid the treatment.

This in no way means that you can be treated without your consent. You can control your treatment when you are ill, unconscious or unable to make legally binding judgements through these ways :

  • Appoint someone who is trustworthy to posses the power of attorney. This person is reliable for taking decision in your place.
  • Advance Directive

In the advance directive you can legally give instructions regarding the future care, though this is controlled by state law.



Healthcare organization is restricted under HIPAA for sharing any kind of medical information of the patient. They even have to provide you with the access to your medical records, ability to make changes, keep you in the loop of your health status and also with whom the data is being shared.

There are chances that your healthcare providers are violating these privacy. So you need to make sure that there is  a written contract which can assure your privacy. Your data gets shared among the medical staff, medical billing and coding companies and the vendors in between.



You should ask for an itemized bill and examine it carefully as it may contain added expenses and incorrect information. Sometimes mistakes are accidental but most of the time they are done intentionally.

Always look out for a balanced bill. There are chances that hospitals charges insurance company portion of bill and send you the reminder. Keep a tab on the research law of your state on all these matters before paying.


Keeping the above three rights in mind will help you from being a victim of information breach, overpaying and further controlling your healthcare. In the changing healthcare industry remaining in touch with every aspect is becoming crucial.


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