MACRA Releases Final Rule for 2018 Performance


CMS has issued the final rule for 2018 for the Quality Payment Program (QPP). The QPP program is in the second year of implementation continually trying to adjust the QPP to become more comprehensive and offer better incentives for the providers.

Changes in MACRA will be affecting the reimbursement for the providers here are some things to look for in Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (AAPM).

A thorough analysis of the MACRA 1,653 pages rulebook we have created chosen the rules which will affect your billing to the maximum.

Merit-based Incentive Payment Model (MIPS)

  1. CMS has added leniency for providers affected by natural disasters e.g.:- Fire, Hurricane

For the 2018 rule, CMS has made provisions for uncontrollable circumstances of natural disasters and health emergencies to submit hardship exception applications. This would mean that the CMS would reconsider the advancing-care information for 2017 and for the quality, cost, and improvement for 2018. CMS has also exempted many clinicians for quality, improvement and cost categories in 2017.  The final rule for the following will not take effect from 2018.

  1. For 2017 the final score which would depend on the quality-60 percent, improvement activities-15 percent, cost- 0 percent and for the advancing care-25 percent. For 2018 the performance for 2018 is the quality- 50 percent, Advance care information- 25 percent, cost-10 percent and improvement activities-15 percent.
  1. Bonus Opportunities for providers

Small practices which have 15 or less number of physicians can also 5 additional points if they submit on one performance category. Physicians can also earn upto five more points for treating complex patients. For all patients eligible for Medicare and Medicaid insurance.

  1. Threshold for revenue and patient raised

In 2017, if providers have billed less than $30,000 for Medicare Part B or treated less than 100 patients who are beneficiaries of Medicare Part B.  In 2018, the bare is promoted to $90,000 and 200 patients annually. Individual physicians or physicians of less than a group of 10 can band together to report the MIPS parameters.


Extended Advanced APM by two years

This says that at least 8 percent of physician’s revenue has to be in risk to qualify for the extension of performance for the year 2020. The performance standard will be extended till 2020, this rule applies to the physicians under the financial risk and who are APM under the non-Medicare payers can also qualify for the Advanced APM.

The rulebook also provides information on All-payer combination model which will be available by 2019. This will include the determination and data submission for the model which will allow the physicians to qualify for the Advanced APM.

The CMS rules have had a mixed reception, while some providers have lauded CMS and others say that it could have been better under the new regulations. Some of the physicians supported saying that the administration has continued providing the flexibility for the participation of providers. However some of the feel that the CMS has shied away from the value based just to maintain the equilibrium for the providers.

It seems like the CMS want to ease out the process of value-based payment model for the providers before fully plunging into the model. This will provide with a breather for the individual physicians and small practices.  While in later years how the practices would be taking the leap for the value-based care would be an interesting factor to see.

While ASC and emergency service providers feel left out with non-expected departments where the 10 points where cut-down bringing it from 50 percent to 40 percent.

For more information on effects of MACRA rule on your practice contact us through our medical billing and coding specialist.

Posted in Accounts Receivables, Claims Denials, MACRA, Medical Billing, Medical Billing Company, Medical Billing Services, Medical Coding, Medicare Medicaid, Practice Administration, Practice Management, Revenue Cycle Management (RCM) | Leave a comment

Why You Need Urology Practice “Report Card”?


Are my resources performing optimally and will they perform to reduce my overhead cost? These are few questions asked by an urologist as they gear up for the next year. Most of the urologist is looking towards the high overhead cost of running an individual practice or few urologists asked us to do an auditing for their practice most of the practices were running into high overhead cost which includes resource hiring for urology medical billing along with looking for technology for claim management.

The urology physicians for whom we audited the Revenue Cycle Management (RCM) throughout the year they asked us a question why should I audit or track my billing every month?

Now as we move from fee for service to value-based model payment the question becomes imperative to answer as we see a different perspective on the reimbursement and each month audit of billing and practice would become as important as patient care. Although every urology practice is non-tangible in terms of the already established system for the patients.

  1. Creating a benchmark for reporting
  2. Total Charges
  3. Total Payment
  4. Total Adjustments
  5. Total Patient Visit
  6. Ending Account Receivable (AR)
  7. Total Patient AR
  8. Total Insurance AR

Need to understand that setting a benchmark for each of the above will let you determine the how well your urology practice is performing and evaluate the changes you required to make. All the above fields might not be needed for your urology practice but you can still make sure you can capture the maximum of data for benchmarking.

You also have to use same benchmarks to determine the performance of your practice. Take all variables into consideration such as time of billing, account vacations, the timing of charges, etc. before you can conclude on the benchmark factor.

  1. Tracking the use of Codes

The number of times each code is used will provide you with an evaluative option of how many times a CPT code is used by you for practice. This will provide you with easy mapping option for you to double check on surgeries and guide through the evaluation/ management through the month. Coding reports create an easy channel for connecting the physicians to a billing department with providing an in-depth knowledge a practice.

  1. Average charge/ visit, and payment/ visit

Average Charge/ visit helps in tracking the Account Receivable (AR) for each visit from the patient and how much each procedure are earning per visit will provide the patients with a structure of patient earning. Payment/ visit will give you insights on the reimbursement from the insurance and patients.

To provide the final conclusion when you see through all the benchmarks the numbers will tell you what you need to improve your practice and what is going well for your practice? Data should be thoroughly analyzed with keeping in vital signs in mind keeping reporting regular.

Why you need a outsource team of billers and Coders?

An outsource team of revenue managers will provide you with all the necessary reports for analyzing the Revenue Cycle Management (RCM). For more information on urology medical billings call us on- 888-357-3226.

Posted in Medical Billing, Medical Billing Company, Medical Billing Services, Medical Coding, Medicare Medicaid, Practice Administration, Practice Management, Revenue Cycle Management (RCM), Urology Billing | Leave a comment

How can Podiatrists Shift the Preventive Care from Fee-for-service to Value-based Care?

How can Podiatrists Shift the Preventive Care from Fee-for-service to Value-based Care?

In the rapidly changing healthcare landscape, payers are asking Podiatrists to shift from volume-based care fee for service to a value-based reimbursement structure fee for value with a population health approach. This evolution toward value-based reimbursement benefits the patient, the healthcare provider and the payer. Value-based reimbursement encourages healthcare providers to deliver the best care at the lowest cost. In turn, patients receive a higher quality of care at a better value.

Podiatrists are aware of the efforts underway to transition the United States healthcare fee-for-service payment system away from one based on volume to one that is determined by “value” and links costs to improved patient outcomes. The problem with the current system is that patients who stay in service the longest and have the most procedures and therapeutic interventions generate the greatest revenue regardless of whether outcomes are favorable.

For podiatrists who treat Medicare patients, value-based reimbursement is about to get real. The Centers for Medicare & Medicaid Services is gearing up for next year’s launch of its Merit-Based Incentive Payment System (MIPS), which will factor value, and not solely services performed, into the Medicare reimbursement a provider receives.

If that program is a success, other insurers will likely follow suit with pay-for-performance plans of their own.

Understand That Customer Service Is Essential

The patient experience is more than just clinical care. Podiatrist practices will need to change their approach to patient intake by having staff members take on more of a customer service role. This is especially important for recurring patients. Sit down with each patient and help them understand the financial details of their health care, from pre-admission through the entire care process. Increased interaction, patient education, and patient assistance through this hands-on approach dramatically improves the patient experience, and in turn, increases revenue for your practice

The good news is that these challenges are not that overwhelming, and podiatrist professionals have long managed as the market evolves and organizations find the right mix. Here, we’ve identified important key considerations to consider as they prepare for the ambiguous future ahead.

Making Data More Actionable & Meaningful

Today’s health care organizations are accumulating an overwhelming amount of data, including patient-reported information, social determinants of health, clinical and claims data. With all this information, it can be difficult for organizations to sort out what they do and don’t need – but data is only valuable if it results in informative and actionable results.

Bringing all of this data together to form a substantial record that has 360 degree view of each individual can be keys to an organization’s success. This view enables organizations to understand the opportunities for care interventions to ensure quality measures are being met and can provide a deeper level of analytics into areas such as utilization.

Standardizing the Care

In this complex ever-evolving health care industry, standardized care is a beacon among health plans, risk contracts and shared savings programs. In a time where health systems and providers are balancing new regulations, health plan variations and individual people and population demands, adhering to a standardized level of care removes some of the complexities, while ensuring quality and safety are paramount. Processes and metrics to define standardized care help to ensure patients receive consistent, quality care, every time.

Managing Care & Engagement

Engaging with patients goes beyond helping them manage their conditions. Active participation and shared decision-making is vital, and it’s most effective when an individual’s goals are identified in conjunction with the appropriate tools to make it easy and convenient for them to achieve their desired outcomes. For podiatrists, engaging patients depends on the insights generated from actionable, measurable data.

Final Thoughts

Additionally, front-end revenue cycle processes are now more important than ever, meaning that collecting the correct patient data before service is critical to ensuring clean claims. In order to improve revenue, providers should emphasize eligibility authorization, collection of copayments, and collection of patient deductibles.

Value-based reimbursement helps in preparing for an evolving patient population with:

  • Increased access to care, which can lead to more patients and less network leakage
  • A more engaged patient population that is responsible for its own care. Patients in turn want more insight into their care and value for their dollar
  • Increasing market share when patients have more choice in where they receive care

As healthcare delivery moves toward value-based reimbursement, the business model and the care model become increasingly intertwined. Changes made to care processes can have a significant impact on financial performance. Organizations need tools that help them identify their revenue cycle management, cost drivers and provide insight regarding how cost, quality, and care decisions impact the network as a whole.

Posted in Medical Billing, Medical Billing Company, Medical Billing Services, Medicare Medicaid, Podiatry Billing, Practice Administration, Practice Management, Revenue Cycle Management (RCM) | Leave a comment

Why Radiology Facilities Need to Update Their Technology for Reducing Partial Payment?

Why Radiology Facilities Need to Update Their Technology for Reducing Partial Payment?

U.S.A healthcare providers are to adopt digital radiography (DR), the Medicare system will begin reducing payments for exams performed on analog x-ray systems starting in 2017. The year after that, sites using computed radiography (CR) equipment will also see payment reductions.

The New Norms

Medicare payments will be reduced by 20% for providers submitting claims for analog x-ray studies starting in 2017 under a provision in the Consolidated Appropriations Act of 2016, which was enacted into law in December 2015. Starting in 2018, payments for imaging studies performed on CR equipment would be reduced by 7% for the next five years, and 10% after that.

While the law’s provisions on analog x-ray are expected to have a minor impact due to the small number of traditional systems still in operation in the U.S., the reductions in CR payments could have a much broader effect: More than 8,000 CR units are still in service in the U.S. All of these systems must be replaced or imaging facilities will experience payment reductions.

New Radiology Facilities

Radiology procedures are defined as global services and fall in the 7xxxx series of the CPT book. For example, the radiology code 71020 (two view chest, frontal and lateral) is considered a global CPT code, as it consists of the professional component and the technical component combined. The relative value units have been calculated to include the expense for the whole package. When charging for only a portion of a service, a modifier must be appended to the code on the CMS-1500 form to indicate a reduction in reimbursement is owed to the service provider.

The common modifiers in radiology billing are 26; TC, 76, 77, 50; LT, RT, and 59 below are the brief explanation regarding each modifier:

  • 26 -professional component

When a radiologist is only interpreting films or imaging/tracing and is not providing the machinery, this modifier should be added to the code on the claim form. Typically, this occurs when a radiologist is reviewing for a hospital, an ambulatory surgery center (ASC), or a doctor’s office that owns the equipment and provides the staff but requires the radiologist to interpret the images and write reports.

  • TC – technical component

 This modifier covers the expense of the staff, machinery, equipment, and nonprofessional interpretation elements required to provide a radiological film or image/tracing. Oftentimes, a hospital, ASC, or office will use this modifier when submitting a claim for a radiological service performed.

Modifiers 76 and 77 are similar in that they relate to the same radiological service performed on the same date of service; however, the provider of service determines which modifier is selected for the additional service performed.

  • 76 – repeat procedure same physician

 When a procedure or service must be performed again on the same date of service by the same physician, it requires this modifier should be included with the CPT code on the CMS-1500 form.

  • 77- repeat procedure different physician

This modifier should be included with the CPT code for the same scenario involving modifier 76 but when a different physician performs the repeat procedure. (Note: Medicare considers all physicians in the same group practice with the same specialty to be the same physician.)

  • 50 – bilateral procedure

 This modifier relates to circumstances in which both sides of the body are imaged or a procedure is performed on both sides of the body. Do not use this modifier if the code is written as a bilateral procedure or service, as it is expected to be performed on both sides. Also, “both sides” does not mean front and back (AP/PA and lateral); it refers to right and left sides.

  • LT/RT – left side/right side

 Depending on the side of the body that is imaged, one of these modifiers is be appended to the code to reflect only one side was imaged.

The Conclusion

It is important to note that radiologists should not decrease the fees they submit to payers, as payers will do those themselves when a modifier is submitted. However, fees should be increased when modifiers are submitted, with two units added when reporting on one line item because the payer will not automatically increase its reimbursement if the rates aren’t already increased.

It is imperative that general radiology does not get left behind as the rest of the world moves with advanced technology. It can be easy to overlook the impact and importance of general radiology on patient volumes and consequently, the bottom line, as reimbursements are much lower for these types of exams and especially due to the high cost associated with upgrading technology.

However, the clinical benefits and soft dollar considerations can help offset some of the financial burden. Even though the high price of going digital presents a challenge in today’s healthcare economy, it will not be long until we are looking at analog technology as a thing of the past.

Posted in Medical Billing, Medical Billing Company, Medical Billing Services, Medicare Medicaid, Practice Management, Radiology Billing, Revenue Cycle Management (RCM) | Leave a comment