Insurance & Reimbursement

Health Risk Assessment

Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar of risk adjustment or HCC codes, it is time to get on board.

To help the understanding of what is covered under Dental and what may be covered under Medical, review Regence's coverage criteria:  

Coverage under medical or dental benefits is determined by the condition that is being diagnosed and treated, regardless of whether the service is provided by a dentist or a medical doctor.

MEDICAL POLICY CRITERIA

Note: Member contracts for covered services vary. Member contract language takes precedent over medical policy.

I. Dental Services

By: Victoria (Tue, Mar/15/2016) 

Healthcare professionals are being forced to move out of their comfort zones. Sweeping changes are being made to change the way healthcare is provided and paid for.

40% of in-network payments are tied to value. And the traditional fee for service model is expected to disappear over the horizon in the years to come. Payments based on quality of care are increasing and it is imperative for healthcare organizations to address the current, on the ground, challenges, posed by the VBP model.

 

Combined Deskbook Resources

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What is an Other Qualified Healthcare Professional?

To begin to answer this question, let's review the exact wording in the CPT codebook:

If you have worked in billing and reimbursement, you are aware that turning patients over to a collection agency to collect on a debt should always be a last resort. Are your office policies conducive to retaining happy, paying patients or harming the word-of-mouth advertising so important to medical providers today?

UHIN offers an ICD-10 Peer Support Group. 

Mac Jurisdictions Resources (Resource 396)

The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called

What To Do When Your Claim Is Lost

What to Do When Your Claim Is Lost

by Tom Necela, DC, CPC, CPMA
January 2010

Medicare Improper Payment Report for Behavioral Health Services

The following information is from the 2014 Medicare Improper Payments Report by the Department of Health and Human Services.

This table shows the Improper Payment Rates by Provider Type and Type of Error for Medicare Part B claims:

    Provider Type

    Improper Payment Rate

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