Your Billing and Coding Checklist for 2018

TMA’s Payment Advocacy staff work with physicians and health plans year-round to help make sure you get paid correctly and on time. They’ve put together this checklist of things you can do at the start of 2018 to help keep your billing and collections on track throughout the year.

Pay attention to plan year changes. Jan. 1 is the start of a new plan year for many health plans. This means not only the start of a new deductible for patients but also a possible change in some patients’ overall payment and coverage policies. For example, a service that previously did not require prior authorization might now require it. Patients might call you because their formulary has changed and previously prescribed drugs are denied. This is where the new step-therapy law could help you. 

Some patients might have changed insurance carriers. Be sure you have an office policy in place regarding how your staff obtain insurance information from patients, verify insurance benefits, and collect deductibles and coinsurance. TMA Payment Advocacy staff recommend that you ask all patients for a copy of their insurance card and that you use payers’ online eligibility verification tools.  

Note changes in the Medicare fee schedule (see this fact sheet for highlights). Jan. 1 also is the start of a new plan year for Medicare. The 2018 Part B deductible remains the same as for 2017, at $183. Coinsurance remains the same: 20 percent of the Medicare allowed amount/fee schedule. Also pay attention to the following:

Your Medicare patients might have switched from traditional Medicare to a Medicare Advantage (MA) plan or to a different MA plan. It’s a good idea to make sure your Medicare patients are aware of your participation status with Medicare and what MA plans you accept. Novitas’ automated phone system provides MA plan information when verifying eligibility.  

Be sure to follow the correct Medicare fee schedule based on your Medicare participation status and any meaningful use, Physician Quality Reporting System, or value-based payment modifier adjustments (up or down) you might be subject to. Also, take into account that Medicare sequestration, the 2-percent across-the-board that began in 2013, is still in effect.

Your patients’ new Medicare cards will begin arriving in April. The cards will display unique Medicare Beneficiary Identifiers, which will replace the current Social Security-based Health Insurance Claim Numbers. The Centers for Medicare & Medicaid Services (CMS) has information and resources for physicians about this transition.

Be aware of your TRICARE region and payer: On Jan. 1, the North and South TRICARE regions will combine to form the TRICARE East Region under regional contractor Humana Military. However, current South Region TRICARE beneficiaries in the Lubbock and Amarillo areas will move into the TRICARE West Region. The new West Region regional contractor will be Health Net Federal Services, the same contractor that supports Cannon Air Force Base in Clovis, N.M.  

Enroll in Medicaid if you’re an ordering, referring, or prescribing physician in Medicaid, Healthy Texas Women, or the Children with Special Health Care Needs Services Program. Beginning Jan. 15, claims for the payment of items and services ordered, referred, or prescribed within these programs must contain the National Provider Identifier of the physician or other professional who ordered, referred, or prescribed the items or services. The Texas Health and Human Services Commission (HHSC) is allowing a three-month grace period from Jan. 15 to April 16, during which it will deny claims not meeting these requirements, then reprocess them to allow physicians more time to complete enrollment. HHSC has more information on its website, including FAQs.

Claim your annual HPSA bonus payments, if applicable. Before the end of the year, be sure to check the CMS Physician Bonuses webpage, where you’ll find CMS’ annual health professional shortage area (HPSA) bonus payment files for 2018. Check to see if the ZIP code in which you render services is eligible for a HPSA bonus payment, and whether you’ll receive it automatically or will need to add modifier AQ to your claim to receive the bonus payment.

Use the new CPT codes. Jan. 1 means new Current Procedural Terminology (CPT) codes. Be sure to use the correct and most recent CPT codes for all the services you bill. Check with your specialty society to see what information it has on new CPT codes that may affect your billing. 

Reevaluate your practice’s financial policies. Maybe 2018 is the year you start collecting all patient cost shares at or before you provide services. With more patients enrolled in high-deductible health plans, you might need to revise your patient payment policies. Consider providing the patient a written explanation of your charges and the patient responsibility. Don’t forget to remind (or educate) patients that services provided in a hospital setting could include, in addition to your service, services from anesthesiologists, pathologists, radiologists, assistant surgeons, and others (who might not be in network with the patient’s health plan). This avoids complaints from patients about the involvement of these other physicians. This simple step can avoid that cost and hassle. 

Review your 2017 accounts receivable and health plan participation, and start the new year with all open insurance claims from 2017 resolved. Practices sometimes get so focused on the previous year’s accounts receivables that they neglect the current claims. Use this as an opportunity to evaluate how long it took health plans to pay you, the types of denials you received, and the percentage of your patients who participate with your contracted health plans. You can use that information to examine contract profitability and payer mix for future contracting decisions. Look for guidance in TMA’s Contract Clause of the Month articles and on-demand webinar, Take Back the Power: Payer Contract Negotiations. For help with billing and collections management, consider a Revenue Cycle Assessment from TMA Practice Consulting. For more information, call (800) 523-8776, email[at]texmed[dot]org, or read Revenue Cycle Management: Keys to Success, available in the TMA Education Center. 

Refresh your website. If it’s been a while since you’ve given you practice website some TLC, now is a good time to make sure your information is up to date. Replace photos or articles with something new, and think about ways to make it a better resource for patients. Because there are many different networks within each health plan, it’s useful for patients and potential patients if your website lists which networks you participate in (and be sure to keep it up to date). TMA’s endorsed vendor Officite can help you with website design and online marketing. 

Remember TMA is here to help. If you have questions about billing and coding, or payer policies, contact TMA’s reimbursement specialists at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. Also, visit the TMA Education Center for courses about collection techniques, and TMA’s Policies and Procedures: A Guide for Medical Offices. See for more resources.

Published Dec. 18, 2017

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Last Updated On

December 19, 2017

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