Stories with related Professional Interests

G-Code Payment Frustration Persists With Inconsistent Implementation - 06/25/2024

Deepening ongoing physician concerns over Medicare’s add-on code for complex care, two major payers have either reduced payment for G2211 claims or announced plans to stop paying certain claims associated with the code altogether. Read more.

Don’t Forfeit Your APM Incentive Payment; Act Now - 08/14/2023

If you participated in an advanced alternative payment model in the 2021 Quality Payment Program and haven’t yet received your 2023 incentive payment, you have until Sept. 1 to update your billing information – or forfeit the payment.

Pass-Through Billing Generally Not Permitted - 09/14/2022

Pass-through billing occurs when an ordering physician requests a service and bills insurance for it but does not perform the service. Insurance companies generally forbid this practice.

Nickel and Dimed: Physicians Can Avoid Electronic Credit Cards and Their Fees - 07/29/2022

Some small medical insurance companies are trying to force physicians to receive payment via electronic credit cards, but medical practices can avoid this costly problem.

Medicare Advantage Plans Wrongly Denied Prior Auth, Payment Requests, Fed Report Shows - 05/06/2022

About 13% of prior authorization denials in Medicare Advantage likely prevented or delayed necessary care, according to an analysis by the U.S. Department of Health and Human Services Office of the Inspector General. The report also found that nearly one-fifth of the time Medicare Advantage plans denied payment requests when the request met Medicare coverage rules and should have earned approval.

AMA: High Concentration in Insurance Markets - 03/31/2022

Most U.S. commercial health insurance markets are “highly concentrated” among the top insurers in those markets, and evidence strongly suggests insurers are “causing competitive harm to consumers and providers of care.” Those were the findings of the American Medical Association’s 2021 update to its annual study, Competition in Health Insurance.

How to Calculate Underpaid Amount in Prompt Pay Rules - 11/17/2021

Even if the insurance company pays on time but underpays you - if it doesn't pay in full by the statutory deadline, it still must pay you a penalty based on the number of days the payment is late and the underpaid amount of the claim.

Late Fees Under Prompt Pay — How Much and When - 11/17/2021

Let’s say your contracted insurance carrier violates prompt pay laws and misses the deadline for paying or responding to your claim. When can you collect late fees and how much?

Sample Letter: Enlisting Patients Assistance for Claims Payment - 11/17/2021

This is a sample letter regarding a patient's outstanding health insurance payment.

United Walks Back Payment Cut on Nonphysician Billing - 08/05/2021

Following strong pushback from the Texas Medical Association, UnitedHealthcare (UHC) has effectively reversed its payment-cutting policy change on “incident-to” billing for services performed by nonphysician practitioners (NPPs). 

CMS Finalizes Lower-Than-Proposed Cost-Sharing for Marketplace Plans; Enrollment Closes Aug. 15 - 06/17/2021

The Centers for Medicare & Medicaid Services (CMS) has settled on a lower maximum for consumers’ out-of-pocket costs for federal health insurance marketplace plans in 2022 than what the agency proposed last November.

Federal Agencies Adopt Rule Mandating Health Plan Price Transparency - 11/24/2020

A number of health plans will be required to be more transparent about coverage pricing starting in early 2021 after the recent adoption of a rule by three federal agencies.

Blue Cross Bundles Payment for Some Diagnostic Services - 11/16/2020

Effective July 1, Blue Cross and Blue Shield of Texas will cut payments for certain diagnostic procedures. The cut will apply to diagnostic cardiovascular and ophthalmology procedures that are billed for the same patient on the same day.

Mixed Bag: Some Payers Capitalize on COVID Chaos; Others Help Make Care Easier - 10/30/2020

Physicians believe some payers are taking advantage of COVID chaos with their drug policies, but also see some plans taking steps to make care easier during the pandemic.

Insurance Companies Have Denied My Doctor’s Orders, 25% of Texas Voters Say - 01/29/2020

One in four Texas voters say their health insurance company has refused to cover what their physician ordered for them or their families, a new statewide survey has found.

Open Enrollment 2020: Be Prepared for Coverage Changes - 11/13/2019

You’re probably already aware that open enrollment for commercial health insurance plans, including those on the Affordable Care Act Exchanges, opened Nov. 1 and will run through Dec. 15. While some patients won’t make any changes to their coverage, others will make significant changes, including enrolling with a completely different health plan.

System Failure: Houston Practices Fight WellCare for Payment - 09/26/2019

Several Houston-area practices say a botched technology conversion by insurer WellCare after it acquired a Medicare Advantage plan led to prior authorization and network confusion, undue denials, and unpaid claims by the barrelful.

United Healthcare Cuts Consults - 09/04/2019

United Healthcare is eliminating payment for consults in two phases – one that took effect June 1 for certain services, and their complete elimination starting in October. The change is an effort to align with the Centers for Medicare & Medicaid Services policy that eliminated payment for most consults in 2010, but it’s going to make it more difficult for many specialists to get compensated for the extra time and work those services require.

TDI Fines Molina Healthcare $500,000 in Prompt-Pay Order - 04/30/2019

The Texas Department of Insurance (TDI) has fined an insurer whose inability to pay claims on time kept physicians waiting on millions of dollars. TDI dealt Molina Healthcare of Texas an administrative penalty of $500,000 – on top of almost $8 million combined that the insurer paid in penalties and interest to TDI, and to affected physicians and other health care providers.

Humana Revises Peer-to-Peer Review - 10/18/2018

Humana has tweaked its peer-to-peer review process for prior authorization requests, giving physicians contracted with its Medicare Advantage plans another opportunity for review before filing a claim.

TDI Fines Humana Over Inadequate Network - 10/12/2018

The Texas Department of Insurance has fined Humana $700,000 and ordered the insurer to take corrective steps for not having enough in-network anesthesiologists in Harris, Bexar, and Travis counties this year.

Payer Math Multiplies Recoupments - 07/10/2018

When does $187 equal nearly $13,000? When a payer projects overpayments. A weekly audio tip from the National Alliance of Medical Auditing Specialists cites a case in which illegible signatures forced a practice to refund almost $13,000.

Blue Cross to Put Off HMO Emergency Coverage Policy Until August - 06/27/2018

Blue Cross and Blue Shield of Texas will delay for 60 days a new HMO emergency care policy it had originally planned to begin on Monday, June 4.

Some Blue Cross Members Could Pay 100 Percent of ER Bill - 05/01/2018

The Texas Medical Association has reached out to Blue Cross and Blue Shield of Texas to obtain more details on a new HMO emergency care policy at BCBSTX unveiled this week.