Breast Cancer Survivors May Face Insurance Challenges For Reconstruction

Breast Cancer Survivors May Face Insurance Challenges For Reconstruction

Few things can impact someone's life quite like cancer. And those who survive breast cancer are often left feeling a wide range of emotions due to their battle - and their victory. But while it's certainly good news to be a survivor, some challenges may still remain.  ..

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A Closer Look At The WHCRA 

A Closer Look At The WHCRA 

The Women’s Health and Cancer Rights provides mandated insurance coverage protection for women whose breast cancer leads them to undergo a breast reconstruction surgery following a mastectomy. In place since 1998, the bill applies to individual plans as well as employer provided group health plans, and under the rules of the WHCRA, insurance is required to cover numerous aspects of the mastectomy and breast reconstruction. In particular, the following must be covered: ..

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A Closer Look AT AB 72 

A Closer Look AT AB 72 

AB 72 is new California state legislation aimed at reducing “surprise medical bills” for patients seen by out-of-network providers in in-network facilities. The legislation is designed to help patients avoid large medical bills they weren’t expecting or able to handle. The bill amends the Health and Safety Code of California law and goes into effect July 1, 2017. The full bill can be viewed here: ..

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AHCA Passed By House Republicans

AHCA Passed By House Republicans

By a narrow vote of 217-213, the House of Representatives passed the American Health Care Act (ACHA) on May 4th, 2017. AHCA is essentially a repeal and replacement of the Affordable Care Act. An earlier scheduled vote in March failed to gain the support needed to pass, and House Republicans spent weeks working to bring holdouts onboard with the idea. It was initially unclear as to whether or not AHCA would even be revisited by congress, but upon gaining the traction needed the bill was reintroduced. ..

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MIPS Participation Notification Letters

MIPS Participation Notification Letters

Originally slated to be sent in December 2016, Medicare Administrative Contractor are currently sending MIPS (Merit Based Incentive Payment System) participation letters throughout April and May. These Quality Payment Program participation levels are being sent to clinicians enrolled in Medicare Part B. ..

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Payers Becoming Ultra Aggressive Denying Claims 

Payers Becoming Ultra Aggressive Denying Claims 

It looks almost as if payers have taken claim denials to a new level of aggressiveness in the last few years. Payers are creating administrative roadblocks for no useful purpose but to deny claim. We are appealing far more claims than ever before and spending twice the time getting claims reprocessed. Maybe the payers have become emboldened with all the press around ObamaCare and run-away healthcare costs. Maybe they simply it a good business decision when they believe provider staff will give up on claims because it is too difficult or the staff just doesn’t know what else to do. It is probably more profitable for the payers even if they spend extra time on the claims that are appealed. ..

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Avoiding A Medicare Penalty In 2019

Avoiding A Medicare Penalty In 2019

Many healthcare providers have previously decided to accept the various Medicare penalties because they just didn’t see the value to spend the time and energy necessary to meet Medicare’s reporting requirements. The all or nothing nature of PQRS and Meaningful Use meant that providers might be subject to a penalty for some seemingly trivial reason even after they did devote significant time and energy to compliance. The lack of feedback with claims based reporting led many providers to be subject to a penalty even after diligently submitted PQRS information on their claims for the entire year. ..

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Are RACs Contesting Too Much?

Under the RAC, or Medicare Recovery Audit Contractor, program those contracted are paid a percentage of any incorrect overpayments they are responsible for identifying and recovering. This has led to an influx of what some suspect are not entirely accurate payment recoveries. Recently data has begun to suggest that the RAC overpayments are in fact in line with reimbursement standards and when physicians have spoken up to challenge these findings the original payments have usually been found to be appropriate. This raises the concern: are the RACs being overzealous and contesting payments they really shouldn’t be contesting? Are these audits truly uncovering inappropriate reimbursements? ..

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Can Insurance Companies Refuse My EFT Requests?

Per the Affordable Care Act operating standards that went into effect January 1, 2014 health insurance providers must honor medical care provider requests for Electronic Funds Transfers (EFT) and remittance advice. Per CMS if a provider puts in a request for an insurance company to remit payments electronically the health plan is “not permitted” to reject or delay this request because “the transaction is a standard transaction.” Requests for EFT reimbursement are considered HIPAA compliant. ..

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ICD-10 Delayed Until 2015

On March 31, 2014, despite vocal opposition from physician groups, the Senate approved a temporary patch to the SGR (Sustainable Growth Rate) payment formula which was subsequently signed by President Obama on April 2, 2014. This approval comes four days after the House vote. It also will delay ICD-10 by another year. The bill was passed just hours before a 24% cut in Medicare payments to doctors was set to take effect, with a vote of 64-35. ..

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