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71
Billing / Re: Is this legal?
« Last post by Christy on April 17, 2018, 01:01:43 PM »
I appreciate your in SIGHT  (ha ha), Linda!  ;D
72
Billing / Re: Is this legal?
« Last post by PMRNC on April 16, 2018, 12:33:58 PM »
MY personal knowledge of eye care is only from procesing claims and having been to eye doctors and have separate vision plan myself.

Where I go they don't routinely do the pressure test unless you schecule for it and unless there is suspect for certain conditions like glaucuma. When I schedule my visit they always ask me first. My own plan will pick up the IOP for suspect either on day or another day. So no, I don't think the doc is doing anything wrong UNLESs he's not using the proper E/M and of course the patient's benefits and coverage should be taken into consideration.
73
Billing / Re: Is this legal?
« Last post by Christy on April 16, 2018, 11:48:32 AM »
thank you, Michele.

In my case, I get a comprehensive eye exam under my insurance once every 2 years at no charge as a preventative exam.

because the doctor's office seems to be unbundling the eye pressure exam, I have to come back on a separate date which is an inconvenience, and I also will have to pay out of pocket for the service (I have a large deductible.) My feeling is that they should do the entire eye exam on one day and if they don't like the payer policy then consider ending the in network agreement with them.

74
NPI Numbers / Re: Unlicensed Clinicians billing under a supervisor
« Last post by Michele on April 16, 2018, 10:07:23 AM »
I work for an EHR for Mental Health provides. There is a lot of confusion in the organization that I work for about NPI's. So I have a few questions.

1. Do you need to be licensed to get an NPI

Not all specialties require a license to obtain an NPI.  However some do.  You didn't mention what types of providers these are (other than mental health).  Are they LPCs, LCSWs, PhDs?

2. If you are unlicensed, can you bill under the supervisors NPI? If so, where does that info go on the claim?

This is not in my scope.  However, I believe that while a provider is still working towards getting their license their services are billed under the supervising provider's NPI.


3. If you are licensed, and billing electronically, you must have your own individual NPI correct? even if you are billing with a group NPI in box 33b?

Thanks!!!!

There must be a rendering provider (individual) NPI showing who performed the services even when billing under a group NPI.


Hope that helps!

75
Billing / Re: Is this legal?
« Last post by Michele on April 16, 2018, 09:29:31 AM »
I don't believe they are doing anything illegal.  We actually have providers that have similar scenarios.  When services are not covered separately if performed on the same day the provider can advise the patient that they must come in on separate days.  We have providers that don't like to do this because it is an inconvenience to the patient, but they have no choice.  In many cases (at least what we see) they are two very distinct services, but for whatever reason insurance doesn't allow them separately on the same day.

76
NPI Numbers / Unlicensed Clinicians billing under a supervisor
« Last post by Brookeyz on April 13, 2018, 12:58:35 PM »
I work for an EHR for Mental Health provides. There is a lot of confusion in the organization that I work for about NPI's. So I have a few questions.

1. Do you need to be licensed to get an NPI

2. If you are unlicensed, can you bill under the supervisors NPI? If so, where does that info go on the claim?

3. If you are licensed, and billing electronically, you must have your own individual NPI correct? even if you are billing with a group NPI in box 33b?

Thanks!!!!
77
Billing / Re: Percentage-based billing agreements are not illegal in California
« Last post by PMRNC on April 12, 2018, 12:36:29 PM »
I had seen this to by another publication. But have questions myself which I'm researching. First.. California state may not have any baring from this ruling to change HHS or interpretation of HHS or federal ruling..THEY can invoke and interpret State...but not federal.

Now ASIDE from the legal judgment by state of CA.. I have comments regarding the comment:

Quote
Percentage-based billing contracts are the rule among private practice healthcare practitioners. In speaking with healthcare billing consultants, I learned that these contracts are commonly misunderstood by the government agencies overseeing Medicaid. And such mistakes can have disastrous consequences for the naÔve healthcare providerís practice. If she or he capitulates to the governmentís demand to switch to a fee-based billing contract, the practitionerís business is changed significantly for the worse. And if she or he argues the point, a protracted legal battle ensues because there is no legal precedent to turn to.

This would be a HORRIBLE argument when trying to overturn any HHS ruling. Mainly because % based is merely ONE method of reimbursement and CERTAINLY is NOT considered the best method for a physician. If it were, we'd have in-house employee's being reimbursed based on % and that simply is not going to happen.  The main argument on behalf of a physician is that it's the "norm" and it's "fair"  however, it still leaves a LOT of vulnarability for the physician since the outsourced billing company is servicing them based on that %. WHILE I get that the OIG opinion was years ago, nothing has changed in that opinion to say otherwise.

NOW from a billing company prospecive, this NORM of % based billing is old and tired and quite frankly degrading in regards to  fair wages. A billing company spends a LOT of time on many different cases and sometimes the outcome is $0.  I, and other billing companies do NOT pay my tax guy a % of my income tax, I don't pay my utilities based on a % of my income so why on earth should we conitinue to consider it a norm to be paid a % of a clients revenue?  Billing companies are leaving money on the table.. A LOT Of money.

To say that a doctors practice is dependent on paying a billing company a % IMHO is ridiculous...If they pay an in-house biller $10 an hour OR an outsourced company $20 an hour they still win and save a LOT of money going outsourced! 

I simply believe that our industry (billing) has created a FALSE misconception that % is the way to gain the client and that the medical practices have followed suit thinking that paying a billing company a % is the better way. This industry has come to believe that the "We don't get paid until you get paid" has run it's course. OFFSHORE medical billing companies have contributed to this deranged way of thinking.. noteably companies such as the one in NJ that uses offshore and is able to promote 4% as their rate.

FACT:  billing on a % leaves a billing company wide open to the possibility of billing fraudulantely (intentionally or not)
FACT:  Service based businesses IN GENERAL do not charge based on a %.
FACT:  Physicians don't save money simply because a service business charges a %.

In light of all these facts. I don't see the California case ruling changing anything on a larger scale. Take NY for example...this would NEVER have stood up becaus of NY law where physicians cannot enter into a fee-splittng relationship with medical providers...PERIOD. The law is so VERY clear in the state of NY as it is in other states. Furthermore, billing companies that disregard state law don't just jeopordize their own contracts, but they also put a LARGE burden on the physician violating the fee-splitting laws in their state. There are several states where this isn't even a grey area..but still billing ocmpanies (MOSTLY THOSE OFFSHORE) disregard this law because THEY have not broken the law, the physician or pracitce has.   

So in conclusion, I don't see this changing anything significantly. I still feel like moving away from % based billing is where the industry is heading.
78
Starting Your Own Medical Billing Business / Re: Asking for a fee increase
« Last post by williamportor on April 12, 2018, 11:43:01 AM »
Thank You everyone. Good ideas.  :)
79
Billing / Re: PODIATRIST BILLING
« Last post by PMRNC on April 11, 2018, 02:36:52 PM »
I agree with Michele, if you already "feel" it's not right, it's probably NOT right. Routinely adding a modiier on your own is probably dangerous business if you are not a certified coder and not looking at the documentation you are billing. Even if you are a certified coder, the liability is the same, your putting yourself at risk by doing something routinely as you describe. It's probably UNLIKELY that every visit your appending the modifier is warranted so you really want to take a look at what your looking at in coding. Cover yourself.



80
Billing / Re: Medicare Form 1490-S
« Last post by Christy on April 11, 2018, 12:56:42 PM »
thanks ladies! I was able to successfully appeal the claims and get them paid without the rigmarole of getting this form.

It was only a problem with certain new NY Anthem BCBS EPOs- the older plans always paid no problems. Hopefully Anthem EPO will catch on soon!
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