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
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
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
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
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 practice.consulting[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 www.texmed.org/GetPaid for more resources.
Published Dec. 18, 2017
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