By Emilie DiChristina for PracticeFirst

In our last issue of our practice newsletter we discussed the financial risks associated with the Affordable Care Act related to the extraordinarily long grace periods for non-payment of premiums. Refer back to our PracticeFirst Blog to review.

By now, we hope that you have advised all of your front end staff of the importance of getting financial agreements signed at the start of 2014, regardless of the type of insurance or length of time an individual has been your patient, AND we hope that you have amended your financial agreement to include “failure to pay premiums resulting in loss of coverage”.

So…now on to a yearly reminder which can also adversely affect your practice’s finances – this of course is the fact that at the start of the year many people start with high-deductibles and co-insurances which may  essentially mean that the patient should in fact be paying the entire cost of a visit up-front.

What has your practice done in preparation for this yearly event of increased risk? Are patient’s advised at the time appointments are scheduled that they will be responsible for their deductible or co-insurance? Have you a payment plan established for your office and your patients? Have you updated your fee schedule for self-pay patients? Do you have a credit-card on file policy?

Remember that this is a yearly rite of passage for practices which has been getting more difficult and places practices at more financial risk each year because co-insurances and deductibles are rising each year!

The impact on the patient of increasing health plan deductibles and co-pays is bad, but for your practice it can be financially devastating because collecting these (essentially self-pay) amounts is difficult to say the least.

This cost-shifting to patients has been increasing each year, but is also expected to be a major concern under the ACA because the law requires people to have insurance while allowing plans such as the “Bronze” or catastrophic plan. These plans have a high deductible and a lower premium. So, just as employers see the benefit in having their employees enrolled with a high deductible plan (although they often offered an HSA to balance the effect on the employee), the ACA allows these “Bronze” plans to allow people to meet the mandate but at lower cost.

It all shapes up to another risk to your practice, unless you have a strong front end staff, a dedicated collections program and a practice administrator who understand the issues related to balancing customer service with effective revenue management.

So what do you need to do?

  • Ask us for help, if you need it!
  • Remember that ANY owed amount should be collected at the time of the service (or that signed agreements to pay and payment plans are in place at the time of the service).
  • Remember that deductibles, unlike co-pays, are often harder to collect as the office may not know what the deductible is – UNLESS, the front end staff verify insurance and patient responsibility BEFORE the visit! This requires your front end staff to understand the value and risk of performing or failing to perform the verification.
  • Make sure that insurance verification is done for EVERY visit because as we noted, under the ACA, patients may change insurance coverage frequently or not have paid their premium and be under the last 60 days of the grace period (which means service at your own risk!).

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By Jennifer Kladke, Credentialing Coordinator

New York State Medicaid

We would like to inform all of our clients who are enrolled in NYS Medicaid, that they now require all billing providers to sign up for EFT and either ERA or PDF remittances.

What this means is existing enrolled providers will be receiving notices with their yearly Certification Statement, indicating (based on their existing enrollment information) whether they need to complete and submit the EFT and/or ERA/PDF forms in addition to the signed and notarized Certification Statement.

 **Note, with the EFT form we will be asking for Entity and/or Personal Banking information to provide to Medicaid.

The Credentialing Department will be completing these forms and sending them out to clients starting this month. It is important to return the paperwork as quickly as possible.  If Medicaid does not receive it timely, they will reject electronic claim submission until the EFT/ERA forms are on file.

Should you have any questions or concerns please contact Jennifer Kladke


By Becky Amann, Compliance Manager

OIG’s STRATEGIC PLAN 2014 – 2018

OIG’S strategic plan focuses on four goals and priorities

  • Fight Fraud, Waste and Abus
  • Identify, investigate and take action when needed
  • Key focus areas include: Medicare and Medicaid program integrity and waste in HHS programs. They will also continue implementing and refining protocols for self-disclosure of wrongdoing.
  • Hold wrongdoers accountable and maximize recovery of public funds
    • Key focus areas include: Identifying and recovering improper payments and utilizing exclusions and referrals for debarment to protect HHS programs and beneficiaries.
  • Prevent and deter fraud, waste and abuse
    • Key focus areas include: Promoting compliance with Federal requirements and resolving noncompliance; advising HHS on key safeguards to prevent fraud, waste, and abuse, and assessing whether providers and suppliers, grantees, and others are qualified to participate in Government programs.
  • Promote Quality, Safety and Value
    • Foster high quality of care
      • Key focus areas include: Promoting quality of care in nursing facilities and home- and community-based settings, access to and use of preventive care, and quality improvement programs.
    • Promote public safety
      • The OIG will continue to prioritize fraud investigations that have public safety as well as financial implications and to look for comprehensive solutions.
    • Maximize value by improving efficiency and effectiveness
      • The OIG will work to ensure that HHS programs do not overpay for services or products relative to their value in the marketplace.
  • Secure the Future
    • Foster sound financial stewardship and reduction of improper payments.
      • OIG will continue to prioritize work on billing and payment errors by providers, effective program administration and contract oversight, and inefficiencies that result in wasteful spending.
    • Support a high-performing health care system
      • As HHS manages the transition to payments based on value rather than volume, the OIG plans to conduct reviews and recommend changes to maximize overall value, protect program integrity, and foster value and high performance.
    • Promote the secure and effective use of data and technology
      • Key focus areas include: the accuracy and completeness of program data (e.g., Medicaid data), the privacy and security of personally identifiable information, and the security and integrity of electronic health records.
  • Advance Excellence and Innovation
    • Recruit, retain and empower a diverse work force
      • The OIG will continue to invest in their workforce by recruiting and retaining talented employees and by maintaining workforce excellence and the highest standards of professional conduct.
    • Leverage leading-edge tools and technology
      • The OIG maximizes their returns on their investments by leveraging data analytics and technology to inform their decisions about where to best direct their resources.
    • Promote leadership, vision and expertise
      • The OIG focuses on building leadership and expertise to drive positive change.

To view the complete strategic plan, please access the OIG’s website at:



By Sarah Howarth, Billing Manager


The Medicare Part B annual deductible for 2014 will be $147.00. Co-insurance remains at 20%.


Medical Record Documentation Standards: Monitoring for Quality Care – Excellus Newsletter Nov. 2013

Excellus BCBS is required by state and federal regulatory bodies, and by NCQA, to monitor primary care physician’s medical record documentation for quality and compliance. To support this requirement, they have established medical record documentation standards. These standards promote efficient and effective assessment, treatment and health promotion and are designed to facilitate confidential coordination and continuity of care over time.

Annually, a review of medical records from a random sample of physicians meeting eligibility criteria is conducted. This is done to assess the quality of their physician’s medical record-keeping practices and compliance with these standards. The performance goal set forth by Excellus BCBS is 80 percent or higher.

Physicians scoring 80 percent to 89 percent are notified that, while meeting the threshold, opportunities for improvement exist. Those physicians identified as not meeting the standard will be required to submit a corrective action plan. Excellus will conduct subsequent reviews within six to 12 months, until the standards have been met for two consecutive reviews.

 The score is based on points achieved through the following documentation categories:

Biographical/Personal Data  General Chart Organization  Personal History  Social Habits Office Visit/Follow-Up  Preventives Services

Opportunities for improvement have been identified for the following criteria points:

Advance Directives  Substance Use  HIV/STD Risk  Patient Safety

In addition to adherence to these standards, Excellus requires that participating provider medical records are kept in a manner that is confidential, current, comprehensive and organized; complies with all state and federal laws and regulations; and is retrievable by the treating provider and Excellus.

Note: Medical record documentation auditing and reporting are part of “health care operations” as defined by HIPAA and, do not require patient authorization for release of protected health information.


As with Univera, Excellus will soon be introducing their Clear Coverage electronic preauthorization capability. This tool will be accessible via the provider portal of their website. Excellus indicates that this feature will provide faster turn-around times to ensure appropriate responses for service requests that require preauthorization. A pilot program will be rolled out to a small group of providers in the last quarter of 2013 and should be operational for all providers in 20