May 20, 2022 | By Toni Elhoms, CCS, CPC, CPMA, CRC I know I am not the only one who is completely appalled by the recent bombshell story on Cigna’s shady claims adjudication practices. ProPublica recently published a scathing article that pulls back the curtain on “PXDX” – a cost-containment strategy deployed by Cigna…
In the expansion category of the 2021 documentation guidelines, there’s some information that may be a little confusing that would like to review with you in Today’s Take. On page 23, under Initial Hospital Inpatient or Observation Care, under the New and Established Patient, there’s a paragraph that reads a little confusing: “If a consultation…
January 13, 2023 | By J. Paul Spencer, CPC, COC A major change to appeals submissions is set to begin on February 1st, 2023 that will effect practices and facilities across the country. United Healthcare (UHC) is mandating the submission of electronic reconsiderations and appeals for most types of claims and plans under their…
October 14, 2022 | By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC Why is it that payors often, can’t or won’t comply with their own reimbursement rules or guidelines for processing/adjudicating claims? Some (who are contracted to The Centers for Medicare and Medicaid Services (CMS)) may view this blog in a negative…
Have you given much thought to an encounter that you might review that actually has CPT or ICD-9 codes documented or included right in the EMR-produced note? (Yes, I do start off many conversations just that way. To be in my head… it’s a scary thing!) So, here’s my question to you: What happens when…
September 30, 2022 | By Christine Hall, Senior Consultant, CHC, CPC, CPB, CPMA, CRC, CEMC, CPC-I Certified Instructor Coordination of benefits can be described as when two or more insurance plans work together to determine the order of coverage liability. This coordination between plans exists to avoid duplicate payment, which could result in…
September 2, 2022 | By Bryan Meek, Esq., Brennan, Manna, and Diamond Patients missing their healthcare appointments without adequate notice can cost practices a lot of money, as well as deprive patients of necessary care. While one solution to mitigate this damage is to charge patients for missed appointments, policies should be written…
August 12, 2022 | By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC Self-audits are critical. They demonstrate compliance, or at least a “good-faith effort” to be compliant; they minimize refunds of overpayments to “actuals” and also mitigate the potential for a multiple being added. Most importantly, they prevent an auditor, agent, or…
July 1, 2022 | By Stephanie Allard, CPC, CEMA, RHIT After all the hype surrounding the upcoming Cigna policy regarding modifier 25 and pre-bill reviews, it seems as if Cigna is not planning on implementing the policy as planned on August 14, 2022. At the time I am writing this, there is recent news…
June 17, 2022 | By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC I am constantly being asked what can be done when government and commercial payors are slow-walking claims for payment. The simple answer is to know your state and federal law. First, let’s tackle the federal law which is 42 CFR…