AMA on Track to Revise E/M Codes — Set New Documentation Guidelines

The AMA’s CPT Editorial Panel approved sweeping changes to documentation and code selection guidelines for evaluation and management codes.

If finalized, the changes would shift the way practices select codes for both office and facility visits as soon as January 2021.

Approved changes include:

• Deleting level 1 office new patient E/M code 99201.
• Removing history and exam as key components for selection of the E/M service level. The practitioner would be required to document that these elements were performed in order to report an office visit code.
• Practitioners would select E/M codes based on either 1) the level of medical decision making (MDM) or 2) the total time spent performing the service on the day of the encounter.
• A plan to revise the E/M guidelines into three sections:
  • Guidelines common to all E/M services
  • Guidelines specific to office and other outpatient visits
  • Guidelines specific to E/M services in the facility setting, including observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home or custodial care and the home setting.
• A major overhaul of the MDM documentation guidelines to emphasize complexity of the conditions being addressed in place of the number of diagnoses reported.

Read more details and find out how you can make your voice heard on these proposed changes at the Part B News blog.

Source: DecisionHealth (3-12-19)

Not Otherwise Classified (NOC) codes are used for services that do not have an existing CPT code that accurately identifies the service or procedure performed. Services billed under NOC codes will be denied as billing errors if codes describing the services are available. Wisconsin Physicians Service (WPS) Government Health Administrators (GHA) has recognized a reoccurring issue with NOC code descriptions. A large number of claims are being submitted with NOC codes, with missing or inadequate descriptions of the provided services.

NOC services, drugs, and biologicals can be correctly reimbursed by the WPS GHA only if providers indicate the following in the 2400/SV101-7 data element or Item 19 of the CMS 1500 form:

• A complete description of services performed. The description must have enough information for the reviewer to adequately determine coverage and compare pricing for similar services.
• The name of the drug/biologic, dosage, and method of administration.

Examples of good descriptions:

• Stab Phlebectomy of Varicose Veins 1 Extremity 6 Stab Incisions
• Arthroscopic Decompression of the Suprascapular Nerve
• Injection, Factor VIII FC Fusion (Recombinant), per IU: 25,000 units

Examples of inadequate descriptions:

• Not Otherwise Classified
• Biologic Injection
• Drug Administered

Providers should list one unit of service for the NOC code in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. NOC drugs and biologicals should not be quantity-billed, even if multiple units are provided. Narrative information is used to determine the payment for these codes. Documentation submitted with a claim must also support the described service. Claims without adequate descriptions and units of service may be rejected or denied.

Contact Yeo & Yeo Medical Billing & Consulting’s Certified Professional Coders for assistance with diagnostic or procedural coding.

Source:WPS Government Health Administrators

The Qualified Medicare Beneficiary (QMB) program provides help with Medicare premiums and cost-sharing for enrolled individuals. More than one out of eight people with Medicare are in the QMB. Medical providers are prohibited by federal law from billing people in the QMB program for Medicare deductibles, coinsurance, or copays. Providers may bill state Medicaid programs for those costs. Providers are subject to sanctions if they inappropriately bill those enrolled in the QMB program. Therefore, it is important for clinicians to implement processes to ensure that they comply with QMB billing requirements.

Providers should regularly identify the QMB status of Medicare beneficiaries in their care before billing for services. Medicare provides several resources to aid clinicians in this process.

• HIPAA Eligibility Transaction System (HETS) – This application allows providers to check updated Medicare beneficiary eligibility to prepare claims and bill services appropriately.
• Medicare Remittance Advice (RA) – Providers should check their Medicare RA. The Centers for Medicare & Medicaid Services (CMS) has reintroduced the QMB information on the remittance advice.
• Michigan Beneficiary Eligibility Verification – Providers should also check state automated Medicaid eligibility verification systems.

Billing errors occur and should be corrected as soon as possible. If a QMB participant is incorrectly billed, the charges should be recalled and all invalid charges paid should be refunded.

At Yeo & Yeo Medical Billing & Consulting, we help our clients bill beneficiaries correctly for services and ensure that their practices comply with QMB billing requirements. Please contact Yeo & Yeo Medical Billing & Consulting with questions.

The Merit-based Incentive Payment System (MIPS) is a program through which participating providers are evaluated and rewarded for improvement based on their performance in four categories. Performance is measured through data reported in four areas:

1. Quality – 45%
2. Promoting Interoperability – 25%
3. Cost – 15%
4. Improvement Activities – 15%

The weighted scores in these categories are combined to determine the comprehensive assessment score. Participating providers can submit data for the 2018 performance year until April 2, 2019, at 8:00 p.m.

The MIPS performance period for 2019 is from January 1, 2019, to December 31, 2019. Data must be collected for the full year for the Cost and Quality categories. For the Improvement Activities and Promoting Interoperability categories, data must be collected for at least a consecutive 90-day period.

Data for 2019 should be submitted to MIPS by the March 31, 2020, deadline to receive a positive, negative, or neutral payment adjustment in 2021.

The Centers for Medicare & Medicaid Services released videos to help MIPS participants with the process. The videos are intended to ease the burden of enrolling and participating in the program and cover a range of topics. Topics include how to register and set up a Quality Payment Program (QPP) account, how to add and approve authorized users for your practice, and how to connect your account to a group practice. Additional videos are available that show step-by-step instructions for how to view, submit, and manage your practice’s data.

For more information about MIPS and the QPP, visit:

• Yeo & Yeo Medical Billing & Consulting’s blog article: 2019 Quality Payment Program – Final Rule
• Quality Payment Program website: https://qpp.cms.gov
• Quality Payment Program video series: MIPS Video Resources

The Centers for Medicare and Medicaid (CMS) released two new voluntary payment models for Medicare Advantage and/or Medicare Part D plans to further the value-based payment agenda. Both will run from 2020 through 2024.

Updated VBID

The first model is an updated version of the Value-Based Insurance Design (VBID) model. To reduce Medicare expenditures, increase the quality of care for Medicare beneficiaries, and improve efficiency, the CMS is testing this VBID model. This updated model extends access to Medicare Advantage (MA) plans to all 50 states. The eligible plan types are expanded to include Regional Preferred Provider Organizations and all Special Needs Plans (Chronic Condition SNPs, Dual Eligible SNPs, and Institutional SNPs).

The application period for 2020 is open now through March 1, 2019. Eligible clinicians can apply to test one or more of the new interventions:

• Value-Based Insurance Design by Condition, Socioeconomic Status, or both
• Medicare Advantage and Part D Rewards and Incentives Programs
• Telehealth Networks
• Wellness and Health Care Planning

Part D Payment Modernization

The second model is called Part D Payment Modernization. Patients, providers, and plans that choose drugs with lower price lists receive incentives through this five-year model. This model is created to test the revised Part D program and incentives on all Part D prescription drug spending and beneficiary costs. It is hoped that this model will reduce Medicare expenditures while maintaining quality care. Prescription Drug Plans and Medicare Advantage-Prescription Drug Plans are eligible. At this time, the application is open only for the calendar year 2020. However, the CMS may offer more application periods in the future depending on the success of the model.

For more information about these new payment models, visit:

MA Value-Based Insurance Design Model

Part D Payment Modernization Model

MGMA groups came together to write to the Centers for Medicare & Medicaid Services (CMS), asking them to extend the application deadline for accountable care organizations (ACOs) that wish to participate in the Medicare Shared Savings Program (MSSP) beginning July 1, 2019.

The CMS announced in December that the applications would be due on February 19, 2019. The letter from the MGMA requests that the application deadline be extended to March 29, 2019. The MGMA groups are concerned that the final rule for the program, which was published on December 31, 2018, is complex and that applicants are still familiarizing themselves with how they can successfully participate in the program.

They argue that additional time is necessary for ACOs to evaluate their options and complete the application’s requirements. ACOs are not always a single provider, but often are large physician groups, hospitals, and nursing facilities. Large practices like this are struggling to meet the February 19 deadline because they must have several boards sign on to finalize applications. The MGMA groups believe it is likely that the time-crunch will cause program participation to suffer.

The MGMA groups understand that the CMS must work within a timeline, but they express a desire for the MSSP to be sustained long-term and are concerned that the deadline will affect this.

See the letter written by the MGMA coalition. Yeo & Yeo Medical Billing & Consulting will follow this issue and communicate new developments.

The Medicare Learning Network has released an article reiterating current Medicare policy. This information concentrates on the date(s) of service to submit when billing for these services. For those providing the services included in the document linked below, please take advantage of the information available and visit the Centers for Medicare & Medicaid Services website. 

View the Guidance on Coding and Billing Date of Service on Professional Claims. 

2019 will be another busy year in healthcare. Highlighted below are ten laws and regulations that will be critical for medical practices in the new year.

1. Participation in voluntary Medicare alternative payment models (APMs) has been relatively static in recent years. Secretary Azar and the Department of Health and Human Services (HHS) are looking to increase participation in risk-based APMs by making performance-based risk a mandatory component of new APMs in 2019.
   
   
2. The Merit-based Incentive Payment System (MIPS) stakes are raised in 2019. MIPS performance determines if clinicians receive a positive or negative payment adjustment of up to 7 percent in the 2021 payment year. For more information on what’s new with MIPS in 2019, see this article: 2019 Quality Payment Program – Final Rule.
   
   
3. HHS has promised to review the Stark Law and Anti-Kickback Statute and other such rules against fraud and abuse. It can be expected that rules to expand exceptions and protect value-based arrangements will be proposed in 2019, though influential reform will likely require the involvement of Congress. These updated rules will benefit providers willing to take performance-based risks.
   
   
4. Legislators will likely continue their efforts to reduce regulatory burdens on medical practices participating in government healthcare programs this year. The “Patients Over Paperwork” initiative by the Centers for Medicare & Medicaid Services exemplifies the intention to increase quality patient-focused care. The promised regulatory relief has been moderate at best, thus far, according to a poll of Medical Group Management Association members. However, this issue remains high priority going into 2019.
   
   
5. Further anticipated efforts for 2019 include those to empower patients by giving them improved access to healthcare cost information. This will reduce the surprise and sticker shock of receiving hospital bills that has received media attention in the past.
   
   
6. The requirements of the 21^st Century Cures Act are expected to be met when the Office of the National Coordinator for Health Information Technology (ONC) releases regulations to improve data sharing between healthcare entities. The goal is to develop a framework that allows the movement of data between health information exchange entities. This includes specifications for the use of apps to efficiently and securely move administrative and clinical data between providers and patients via their Electronic Health Records.
   
   
7. HIPAA enforcement is likely to increase audits and fines in 2019. Medical practices are targets for cybersecurity attacks because of the patient, clinical, and financial data they possess. Many times medical practices do not have adequate protection against such attacks. Comprehensive risk assessments highlighting weak areas should be done to protect data. Yeo & Yeo Technology has experience in conducting these Security Risk Assessments (SRAs) for healthcare practices. Contact YYTECH with questions or to schedule an SRA for your practice. YYTECH Security Risk Assessment.
   
   
8. Congress is looking to reduce Medicare drug prices in 2019. One proposal seeks to implement a new International Price Index to lower the price of physician-administered drugs in Part B. It also proposes to introduce new vendors to supply drugs to practices and set a flat fee for drug administration cost. CMS would like to increase the flexibility of Part D drug plans to negotiate prices in protected classes.
   
   
9. Continued efforts will be made to equalize Medicare payments for the same services across clinical sites. This policy was expanded in 2018 by reducing payment for clinic visits at hospital outpatient departments. Site-neutral payments are supposed to save patients and the government money as well as increase market competition.
   
   
10. “Medicare for all” was a key platform for many in the 2018 elections. Though it is unlikely that any major health reform bill will be passed soon, universal healthcare will most likely be a point of debate as presidential contenders campaign for the 2020 primaries.

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Claims with dates of services on or after 1/01/16 for professional non-physician providers (Psychologists, Social workers, Marriage/Family Therapists, and Professional Counselors) were paying incorrect rates. This has been corrected in CHAMPS as of the December 14, 2018 release to allow claims to properly pay the correct rates, per MSA 15-44 and MSA 15-14.

MDHHS will adjust the impacted claims beginning on pay cycle date 1/17/2019 until complete. The claims can be identified with claim note “Correcting overpayments for non-physicians”.

Providers with further questions can contact provider support by phone 1-800-292-2550 or by email ProviderSupport@Michigan.gov. 

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Effective immediately, there are some notable changes in the statute that governs Medicaid subrogation. The changes address the shortcomings in the old law and provide clarity to the process where possible. These changes include: 

• Defining the process by which “notice to the department” is accomplished. The new statute requires that notice be provided to MDHHS (and any associated Medicaid managed care plan) within 30 days of filing a case and that attorneys certify this notice on the SCAO summons form. A copy of this form, the complaint and all other documents filed with the complaint must be provided to MDHHS and the contracted health plan, if applicable. This change provides a new framework under which attorneys’ offices demonstrate their intent to comply with Medicaid’s right to recover its expenses. (We are working with SCAO on the form change and expect it to be available by February 1.)
• Defining what information must be provided to MDHHS (or managed care plan) at the time of settlement in order for Medicaid to determine its recovery.
• Providing for a specific penalty for each failure to provide notice. An attorney who knowingly fails to notify the department or managed care plan is subject to a $1,000 civil fine.
• Requiring prompt responses from the department and managed care plans or their vendors by specifying that the department and plans must provide detailed responses within 30 days. Failure to provide this information within 30 days releases counsel’s obligation to protect Medicaid’s interest. This new language addresses concerns with poor customer service and unnecessary delays in proceedings due to slow response times.

Lastly, to expedite the process, we are eliminating our internal requirement that attorneys must provide a HIPAA form for casualty subrogation purposes .

We believe these changes add certainty and clarity into the notice process and worked on the language with the Michigan Association for Justice to ensure that your interests were represented. MDHHS values and respects our collaboration in this process and will continue to provide excellent customer service, individualized attention to each case, and reasonable compromises to assist attorneys in your attempts to navigate this process. Medicaid will continue to honor the “50-50” distribution with members and negotiate recoveries with counsel in good faith depending on the terms of the settlement. Please contact us with questions or concerns and we’ll work to address them with you.

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Per Medical Services Administrations (MSA) policy bulletin MSA 18-50 effective for dates of service on and after January 1, 2019 Michigan Department of Health & Human Services (MDHHS) will begin to pay claims for Medicaid beneficiaries who are eligible and not enrolled with Medicare, this includes beneficiaries that are only partially Medicare enrolled (i.e. enrolled in Medicare Part A and not Medicare Part B). The claims will be paid as Medicaid primary, once the beneficiary obtains Medicare coverage Medicare should be billed and the Medicaid claim should be adjusted by the provider to reflect the primary payer processing. If claim adjustments are not performed by providers, then MDHHS Third Party Liability (TPL) will initiate claim voids.

Providers with further questions can contact provider support at Providersupport@Michigan.gov or 1-800-292-2550.

The Quality Payment Program (QPP), established by MACRA, is a payment incentive program that rewards eligible clinicians based on standards of quality and value. Changes have been made to the QPP’s Merit-based Incentive Payment System (MIPS) for the 2019 reporting year, affecting all those who participate in the MIPS program. MIPS performance assessment is split into four categories in which clinicians submit data and are assessed. The assessment categories are: Quality, Improvement Activities, Promoting Interoperability (formerly Accountable Care Information), and Cost. Each category weighs differently into the overall performance score.

Summary of 2018 Requirements

The policies and performance categories for 2018 were built upon those of the previous year. The second year of the program continued to minimize clinician burden, coordinate efficient care, and ensure meaningful processes and outcomes. Last year’s performance category weights were as follows: Quality = 50%, Improvement Activities = 15%, ACI = 25%, and Cost 10%. Combined, these four categories determine the comprehensive assessment score which determines if participating clinicians will receive either a 5% increase or decrease in their payment outcome in 2020 based on the 2018 assessment. Below is a table outlining the point values earned in the assessment and the corresponding adjustment to the payment received in 2020:

Also new last year, the performance threshold was raised to 15 points in the 2018 reporting year. Bonus points were available for clinicians treating complex patients (5 points), being a small practice (5 points), and using 2015 technology when using the 2014 and/or 2015 CEHRT. Virtual groups were included as a participation option for the 2018 reporting year and a policy for situations of extreme and uncontrollable circumstance was put in place. Outline for 2019

The final rule, to take effect January 1, 2019, updates the processes and requirements of the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). The final rule marks the full implementation of the QPP program that has been phased in over the last few years. The following are highlights of the updates for the 2019 reporting year.

The definition of Eligible Clinicians (ECs) is expanded to include additional clinician types including physical and occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and dietitians or nutrition specialists.

There will be a third element added to the low-volume threshold that will allow ECs who meet one or two standards of the low-volume threshold to opt in to participate in MIPS. The new standards for this threshold are: bills $90,000 or less in Medicare Part B, sees 200 or fewer Medicare beneficiaries, or provides 200 or fewer covered professional services under PFS. ECs meeting one or two of these criteria wishing to opt-in can do so on the QPP portal.

ECs participating in the QPP will still be scored 1-100 points based on data in these four performance categories:

Quality (45 points) – ECs must report at least six quality measures for at least 60% of applicable patient encounters (a minimum of 20 cases). Measures that meet a 60% data completeness threshold will receive a minimum score of three points. CMS permits ECs to report quality measures using multiple data collection types, but limits claim-based reporting to small practices. The final rule adds 10 new quality measures, removes 34 quality measures, and continues the rules for “topped out” measures. The reporting period for the quality category is 12 months.

Promoting Interoperability (25 points) – Previously known as “Advancing Care Information,” Promoting Interoperability is using performance-based scoring for each measure. This differs from the use of base, performance, and bonus scoring from previous reporting years. ECs report measures from four objectives and the scores for each measure will be added to determine the overall category score up to 100 points. Two new measures in this category are optional for 2019 and 2020, but ECs will earn up to five bonus points for each measure should they choose to report them. The hardship exemption still stands in this category and is expanded to include the new clinician types listed above. The reporting period for this category is 90 consecutive days.

Cost (15 points) – The weight of this category was increased from 10% to 15% of the final MIPS score in 2019. The cost category continues to assess ECs based on Total Per Capita Cost and Medicare Spending Per Beneficiary. There are eight new episode-based measures that include only items and services related to the episode of care as opposed to all services provided to a patient over a given period of time.  

Improvement Activities (15 points) – ECs continue to report improvement activities as part of their MIPS assessment. The final rule includes six new improvement activities. It also modifies five of the existing activities and removes one. The reporting period for this category is 90 consecutive days.

These four categories combine to determine the comprehensive assessment score. There is still a point bonus for clinicians who treat complex patients that adds up to five bonus points. Below is a table outlining the point values earned in the assessment and the corresponding adjustment to the payment received in 2021:

An alternative to the MIPS assessment is the Advanced Alternative Payment Model (AAPM). Medicare is hoping to see more clinicians participating in APMs and is making revisions to make it easier to participate in the program and more beneficial to these eligible clinicians. Please visit the Medicare website for more information on eligibility and the requirements of this alternative program.

In Conclusion

As QPP advances into the first year of full implementation, the updated reporting requirements will be an adjustment for all participating clinicians. Yeo & Yeo Medical Billing & Consulting stays up to date on the changing requirements of the Quality Payment Program. Please call us with questions or concerns you may have regarding your QPP reporting and assessments.

For additional resources, visit the following websites:

https://qpp.cms.gov/

https://www.qppresourcecenter.com

There continues to be much uncertainty about the Affordable Care Act and how such uncertainty will impact health care costs. So it’s critical to leverage all tax-advantaged ways to fund these expenses, including HSAs, FSAs and HRAs. Here’s how to make sense of this alphabet soup of health care accounts.

HSAs

If you’re covered by a qualified high-deductible health plan (HDHP), you can contribute pretax income to an employer-sponsored Health Savings Account — or make deductible contributions to an HSA you set up yourself — up to $3,450 for self-only coverage and $6,900 for family coverage for 2018. Plus, if you’re age 55 or older, you may contribute an additional $1,000.

You own the account, which can bear interest or be invested, growing tax-deferred similar to an IRA. Withdrawals for qualified medical expenses are tax-free, and you can carry over a balance from year to year.

FSAs

Regardless of whether you have an HDHP, you can redirect pretax income to an employer-sponsored Flexible Spending Account up to an employer-determined limit — not to exceed $2,650 in 2018. The plan pays or reimburses you for qualified medical expenses.

What you don’t use by the plan year’s end, you generally lose — though your plan might allow you to roll over up to $500 to the next year. Or it might give you a grace period of two and a half months to incur expenses to use up the previous year’s contribution. If you have an HSA, your FSA is limited to funding certain “permitted” expenses.

HRAs

A Health Reimbursement Account is an employer-sponsored account that reimburses you for medical expenses. Unlike an HSA, no HDHP is required. Unlike an FSA, any unused portion typically can be carried forward to the next year.

There’s no government-set limit on HRA contributions. But only your employer can contribute to an HRA; employees aren’t allowed to contribute.

Maximize the benefit

If you have one of these health care accounts, it’s important to understand the applicable rules so you can get the maximum benefit from it. But tax-advantaged accounts aren’t the only way to save taxes in relation to health care. If you have questions about tax planning and health care expenses, please contact us.

© 2018

To increase efficiency and better serve providers, Cofinity has implemented a new claim submission workflow.

Effective now through December 31, 2019, providers should send claims directly to the Payer instead of Cofinity. The Payer will then submit the claim to Cofinity. This new method is an industry norm, and Cofinity will continue to reprice claims.

Payers are being migrated to the new claim workflow between now and July 1, 2019. Payers will send updated ID cards to patients between now and July 1, 2019, which will include the Payer’s electronic Payer ID and the mailing address for non-electronic claims. The migration should be complete by July 1, 2019, and all claims should be sent directly to Payers by that date.

Cofinity will no longer accept claims after December 31, 2019.

Now that Affordable Care Act (ACA) repeal and replacement efforts appear to have collapsed, at least for the time being, it’s a good time for a refresher on the tax penalty the ACA imposes on individuals who fail to have “minimum essential” health insurance coverage for any month of the year. This requirement is commonly called the “individual mandate.”

Penalty exemptions

Before we review how the penalty is calculated, let’s take a quick look at exceptions to the penalty. Taxpayers may be exempt if they fit into one of these categories for 2017:

• Their household income is below the federal income tax return filing threshold.
• They lack access to affordable minimum essential coverage.
• They suffered a hardship in obtaining coverage.
• They have only a short-term coverage gap.
• They qualify for an exception on religious grounds or have coverage through a health care sharing ministry.
• They’re not a U.S. citizen or national.
• They’re incarcerated.
• They’re a member of a Native American tribe.

Calculating the tax

So how much can the penalty cost? That’s a tricky question. If you owe the penalty, the tentativeamount equals the greater of the following two prongs:

1. The applicable percentage of your household income above the applicable federal income tax return filing threshold, or
2. The applicable dollar amount times the number of uninsured individuals in your household, limited to 300% of the applicable dollar amount.

In terms of the percentage-of-income prong of the penalty, the applicable percentage of income is 2.5% for 2017.

In terms of the dollar-amount prong of the penalty, the applicable dollar amount for each uninsured household member is $695 for 2017. For a household member who’s under age 18, the applicable dollar amounts are cut by 50%, to $347.50. The maximum penalty under this prong for 2017 is $2,085 (300% of $695).

The final penalty amount per person can’t exceed the national average cost of “bronze coverage” (the cheapest category of ACA-compliant coverage) for your household. The important thing to know is that a high-income person or household could owe more than 300% of the applicable dollar amount but not more than the cost of bronze coverage.

If you have minimum essential coverage for only part of the year, the final penalty is calculated on a monthly basis using prorated annual figures.

Also be aware that the extent to which the penalty will continue to be enforced isn’t certain. The IRS has been accepting 2016 tax returns even if a taxpayer hasn’t completed the line indicating health coverage status. That said, the ACA is still the law, so compliance is highly recommended. For more information about this and other ACA-imposed taxes, contact us.

© 2017

Collection problems are very serious to the financial health of your medical practice. You may find costs and overhead going up while cash flow goes down. To make matters worse, your office is probably spending more time than ever before contending with third party regulations and rejected claims.

• An assessment of your billing and collection process. Is it timely, efficient and accurate?
• An analysis of your fee schedule. Are you charging enough?
• An evaluation of your reimbursement record. Are there steps you can take to improve your reimbursement rate and speed up payments from the slowest patients and payers?
• An examination of coding procedures and claim denials. Can you increase the number of “clean claims?”

Blue Cross Blue Shield’s Physician Group Incentive Program (PGIP) rewards physician organizations’ performance and best practices. The program is designed to improve the quality of patient care and reduce costs. Participating providers contractually agree to allocate a portion of their reimbursement to PGIP, and the allocation is used to fund the PGIP reward pool.

The PGIP allocation percentage has not increased since 2013. However, beginning July 1, 2018, the amount of professional fees allocated to the PGIP will increase from 5 percent to 7 percent. The increase will be used to fund new PGIP systems of care initiatives. The provider’s claims payment vouchers will reflect the increased percentage of the allowed amount, based on the applicable fee schedule.

According to Blue Cross Blue Shield of Michigan representatives, the Blue Cross PPO conversion factors will also increase by 2 percent, together with the PGIP allocation increase. Blue Cross Blue Shield of Michigan is focused on helping Organized Systems of Care (OSCs) to build the foundation for integrated care processes so that they can offer their patients more coordinated care.

The PGIP’s goal has always been to encourage and support providers in creating efficient systems for patient care. The amount of the reimbursement that goes toward developing these effective care practices and rewarding provider performance continues to increase. All PGIP incentive funds are distributed to participating providers to be used for these improvements; no funds are kept by Blue Cross.

For more information about PGIP, contact Yeo & Yeo Medical Billing & Consulting or refer to www.bcbsm.com/provider/value_partnerships/pgip.

It’s not uncommon for businesses to sometimes generate tax losses. But the losses that can be deducted are limited by tax law in some situations. The Tax Cuts and Jobs Act (TCJA) further restricts the amount of losses that sole proprietors, partners, S corporation shareholders and, typically, limited liability company (LLC) members can currently deduct — beginning in 2018. This could negatively impact owners of start-ups and businesses facing adverse conditions.

Before the TCJA

Under pre-TCJA law, an individual taxpayer’s business losses could usually be fully deducted in the tax year when they arose unless:

• The passive activity loss (PAL) rules or some other provision of tax law limited that favorable outcome, or
• The business loss was so large that it exceeded taxable income from other sources, creating a net operating loss (NOL).

After the TCJA

The TCJA temporarily changes the rules for deducting an individual taxpayer’s business losses. If your pass-through business generates a tax loss for a tax year beginning in 2018 through 2025, you can’t deduct an “excess business loss” in the current year. An excess business loss is the excess of your aggregate business deductions for the tax year over the sum of:

• Your aggregate business income and gains for the tax year, and
• $250,000 ($500,000 if you’re a married taxpayer filing jointly).

The excess business loss is carried over to the following tax year and can be deducted under the rules for NOLs.

For business losses passed through to individuals from S corporations, partnerships and LLCs treated as partnerships for tax purposes, the new excess business loss limitation rules apply at the owner level. In other words, each owner’s allocable share of business income, gain, deduction or loss is passed through to the owner and reported on the owner’s personal federal income tax return for the owner’s tax year that includes the end of the entity’s tax year.

Keep in mind that the new loss limitation rules apply after applying the PAL rules. So, if the PAL rules disallow your business or rental activity loss, you don’t get to the new loss limitation rules.

Expecting a business loss?

The rationale underlying the new loss limitation rules is to restrict the ability of individual taxpayers to use current-year business losses to offset income from other sources, such as salary, self-employment income, interest, dividends and capital gains.

The practical impact is that your allowable current-year business losses can’t offset more than $250,000 of income from such other sources (or more than $500,000 for joint filers). The requirement that excess business losses be carried forward as an NOL forces you to wait at least one year to get any tax benefit from those excess losses.

If you’re expecting your business to generate a tax loss in 2018, contact us to determine whether you’ll be affected by the new loss limitation rules. We can also provide more information about the PAL and NOL rules.

© 2018

The professionals of Yeo & Yeo Medical Billing & Consulting are proud to celebrate the company’s 20^th anniversary. Established in May 1998 as an affiliate of Yeo & Yeo CPAs & Business Consultants, the company has grown into a leading provider of medical billing and practice management consulting services, helping physicians, group practices, and healthcare organizations throughout Michigan to thrive.

A proud history

Yeo & Yeo’s Certified Public Accountants have served clients in the health care industry since the firm’s inception in Saginaw more than 95 years ago, but in 1998 the firm elevated the level of services available for physicians by hiring Julia Lowe, a practice management consultant with many years of experience. Affiliated Medical Billing was formed that year with a staff of only Julia and one other employee in Saginaw, MI.

With extensive expertise in medical practice management, Julia helped streamline physicians’ practices by improving their business functions. She provided invaluable guidance on ways to maximize physician reimbursement, keep accounts receivable in control and reduce overhead expenses, and she trained physicians and their billing personnel in all aspects of coding.

The company quickly grew as new clients came from the areas surrounding Yeo & Yeo’s office locations throughout Michigan. By 2006, the company had expanded to more than 20 employees and moved into the building next door to Yeo & Yeo’s Saginaw office to accommodate the growth.

Julia Lowe retired in 2017 and Kati Krueger, who started her career with the entity in 2002 as a co-op student, today serves as its president. In the same year, the affiliate also changed its name to Yeo & Yeo Medical Billing & Consulting (YYMBC) and relocated once more to Yeo & Yeo’s new headquarters on Bay Road in Saginaw.

Decades of technology changes for evolving client service

What is the key to Yeo & Yeo Medical Billing’s success? Krueger says, “We have a great team of medical billers behind us that work hard and strive to get the maximum reimbursement for our clients. We continually educate our staff, so they know the ever-changing policies and rules.”

The technology that the company uses has evolved tremendously during the last 20 years. For example, the medical billers now utilize coding software rather than looking up diagnostic and procedural codes in books. An Electronic Medical Records interface allows the billers to receive a physician’s information electronically, eliminating the need for manual data entry. Also, the company now offers patient portals for bill payment.

Recently the company implemented YeoLEAN Medical Billing, a Lean Six Sigma-based methodology that resulted in a more streamlined reimbursement process, new software capabilities and paperless technology, improved reporting, and timelier communication with clients.

Denise Garrett, Training and Development Coordinator for YYMBC, says, “With today’s web-based connectivity, our clients can see every claim that is outstanding. It is more transparent now for the client and gives them peace of mind that everything is working as it should.”

Constant changes – constant challenges

“The biggest challenge for our clients is the declining reimbursement from insurance carriers. Physicians must follow stricter guidelines, and more rejections are coming through on claims,” says Krueger. “Also, under the Medicare Quality Payment Program, physicians have to report data to Medicare to avoid a penalty.”

Another challenge that physicians face is the rise of high-deductible health care plans, so they have to collect more money from patients rather than from insurance carriers.

YYMBC’s staff faces challenges too, one of which is the insurance carriers’ ever-changing rules. “We have to fight harder for our clients, for less money,” says Krueger. Also, a significant change in medical billing coding – ICD-10, which went from 14,000 codes to 69,000 codes – took effect in 2015, and “the codes still keep changing,” she says.

Demand grows for practice management solutions

With all the challenges and changes, the demand for consulting services has increased. YYMBC’s professionals have earned specialized credentials in coding, compliance, medical audits and practice management. Their expertise in practice management solutions can be combined with accounting and back office services provided by Yeo & Yeo’s CPAs, IT solutions from Yeo & Yeo Technology and wealth management from Yeo & Yeo Financial Services for a full solution. 

Some of the consultative services include:

• Health Insurance Portability and Accountability (HIPAA) compliance audits
• Guidance for increased efficiency in processes and organization
• Fee structuring, annual billing reviews, and chart audits
• Practice transition – startups, mergers and practice discontinuations

What is in the future?

The company will continue to focus on growth, serving new markets throughout Michigan and developing new services while continually working on efficiencies. “We want to create the best experience for our clients, all with the goal of helping them maximize their profitability,” adds Krueger.

While so much has changed in 20 years – the company’s leadership, name, location and technology – Yeo & Yeo’s medical billing professionals foresee an unchanging need for their services. One client says it best:“There is a sense of security and support because you have a team of people available who have expertise in multiple areas, and I have found that billing is more complicated now than ever before.”

Medicare is in the process of removing social security numbers from Medicare cards. This change will help the Centers for Medicare & Medicaid Services (CMS) to prevent fraud and identity theft, and protect beneficiary funding and financial information. Medicare Beneficiary Identifier (MBI) numbers will replace the Health Insurance Claim Number (HICN) on the new Medicare cards. Unlike the HICN, which is based on the beneficiary’s social security number, the MBI is unique, randomly generated and does not have any hidden or special meaning. It will be 11 characters long, made up of numbers and uppercase letters. The MBI is confidential and should be protected like any other personally identifiable information.

The new cards will be mailed beginning in April 2018, and all cards will be replaced by April 2019. Individuals who receive their new Medicare cards may use them right away. The effective date of the new cards is the same as the date the beneficiary was eligible for Medicare.

For health care providers, the transition from HICN to MBI will take place over a 21-month period from April 2018 through December 2019. Several resources are available from the CMS to help providers transition smoothly.

• Open Door Forums are being held online every quarter so that the CMS can get feedback from providers as to how the transition to the new Medicare cards and MBI numbers is going.
• Medicare Card Messaging Guidelines will help providers talk with consumers about the new cards.
• A new Frequently Asked Questions document about the new Medicare card project is available for providers.

The CMS is developing a way for healthcare providers to look up the new MBI through a secure tool that will be available in June 2018. Providers can continue to file claims using HICN numbers during this transition period. When providers submit a claim with a patient’s HICN, CMS will return both the HICN and the MBI on every remittance advice. The MBI will be located in the same place where the “changed HICN” currently appears.

Beginning in January 2020, claims must be submitted using MBIs regardless of the date of service.

For resources and updates to help you be ready for the new Medicare cards, visit the CMS website: https://www.cms.gov/medicare/new-medicare-card/nmc-home.html