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What physician wants to give any money back to an insurance carrier?  Few consumers realize that unlike other business owners, physicians don’t get to set their own prices for services rendered.  Rather, they are on a “take it or leave it” reimbursement system.  So, frustration runs high when a provider is informed that there has been an overpayment on an already heavily discounted service.  These overpayments, result in credit balances.

There seems to be an uptick in the number of practices that are contacted by the State Department of Revenue and told that they are the target of a credit balance audit.  This article, Juggling the Credit Balance Dilemma, is a good overview of why this is happening and the penalties you face if you don’t resolve credit balances.  We hope you take a minute to read the article and then make sure your practice is in compliance.

Dealing with Unmet Deductibles

Unmet Deductible

Unmet deductibles challenge health care practices and interrupt cash flow.  Long gone are the days when collecting patient payables meant collecting $10 copays.  More and more patients have chosen a high deductible health plan to save on premiums and/or take advantage of health savings accounts (HSA).

Unmet Deductible This means that each patient must pay out of pocket for health care services until their deductible is met.  After that, their insurance will pay your claims.  The amount of the deductible varies from policy to policy.  However, the most common amounts range from $200 to $6,000.

Unfortunately, each new year finds patients, providers and clinic staff struggling to meet these deductibles.  Each must find an effective way to deal with the impact when deductibles reset.  Here are a few basics for improving your patient collections.

Tips to Improve Collecting Patient Deductibles

  1. Prior to the patient’s appointment verify eligibility and know what your patient will owe.  This is especially important because patients change insurances which results in changes to the deductibles.
  2. Always verify whether or not a deductible has been been met when you call to verify the patient’s insurance.
  3. Reduce front desk awkwardness and instead tell the patient why they will owe before the appointment.  Letting the patient know what they will owe is critical.  You can even do this when you place appointment reminder calls.  Patients don’t like surprises and they are being educated to understand that they will owe more than a $10 copay.
  4. Make it easy for them to pay and give them options.  Let them pay on a credit card, by cash, check, money order and even PayPal.  Make sure your staff offers to accept payment during the appointment reminder call or when they check-in or check-out.  Also, make sure that you have this payment expectations/information posted in several places in the office, including the waiting area and patient rooms.
  5. Implement a credit card on file policy whereby your patients agree to have all or some of the balance charged to their credit cards each month.  You do not want the liability of keeping their credit card information onsite, so use a certified and secure third party to retain the information.
  6. Promote your patient portal and if you don’t have one – get one.  Online payments are the way to go!  Some patients just want to go online and make a payment.
  7. Collect a flat amount in advance.  If you don’t know how much the patient will owe, then collect a flat amount.  Let the patient know that after the claim has been paid the balance will be billed to them.
  8. Inform your staff of how to collect money.  Your staff should be well-informed of all office and financial policies.  Consider providing staff with scripts to help them collect patient payments.

Time of service collections and lots of communications will help to make collecting deductibles easier and in the long run reduce everyone’s stress during ‘deductible season’.

Is Mod 59 a Magic Bullet?


Mod 59 codingWe’ve noticed an increase in the usage of modifier 59 (mod 59).  Oh we all want a magic bullet.  The code that will get every charge reimbursed the first time.   Although modifier 59 may get the claims paid it might not be the correct usage of the code.  After all there are no magic bullets.

Mod 59 does have a purpose. We asked a certified professional coder to explain when it should and shouldn’t be used.  Here is an explanation that you may find helpful.

Mod 59 is used on services that are commonly bundled and/or are not normally reported together. However, there are certain circumstances can be reported and paid separately.


Adding mod 59 indicates that a procedure or service is distinct or independent from other non-E/M services performed on the same day.  You can use modifier 59 when

  1. the procedure is performed in a different session or patient encounter;
  2. there is a different procedure or surgery;
  3. there is a different site or organ system; or
  4. a separate incision/excision and separate lesions or separate injuries not ordinarily encountered or performed on the same day by the same individual.

For billing, bill all services performed in one day on the same claim.  Add mod 59 to the subsequent procedure if the other procedures are not normally reported together and is appropriate for the clinical circumstances.


If a service is typically included in the performance of the primary procedure then the procedure is bundled and should not be reported with mod 59.  Modifier 59 should never be used when another more appropriate modifier exists to clarify the services performed and when the documentation does not support the separate and distinct status.

The Medicare National Correct Coding Initiative (NCCI) has also addressed the use of mod 59.  One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.  For more detailed information, click here for a copy of the related mod 59 article from the NCCI.

Which Code is the Right Code for 2017 Flu Vaccines?

by Claire Ariyoshi, CPC

Coding Tips for Flu VaccinesRecent CDC recommendations state that vaccination efforts should begin as soon as the seasonal flu vaccines are available and continue through the flu season.  While administering the flu vaccine may be easy, coding and getting paid for it is not.

Flu vaccines are no longer easy to code due primarily to the vast number of vaccines available.  It puts the onus on the provider to know which code goes with which vaccine.  It seems like every year there are changes on how to code flu vaccines.  This year was no different.

2017 Changes

First, there was the January 1 revision.  This changed many of the influenza CPT code descriptions, removed the age indicator and added dosage.  And, it was recently announced that effective July 1, 2017 the new CPT 90682 will be reimbursed by Medicare.  This is specific to the influenza virus vaccine quadrivalent (RIV4) derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free for intramuscular use.  Medicare carriers have until August 1, 2017 to implement the CPT and pay from service dates starting July 1, 2017.

What Codes for Flu Vaccines?

When a flu vaccine is given, the provider should also enter CPT 90471 for commercial or G0008 for Medicare, for the administration of the vaccine.  The ICD10 DX code is Z23.  Just to confuse the issue even further coding is specific to trade name, how supplied, mercury content and age group.  The Immunization Action Coalition, published a table of flu vaccines by trade name to assist you in selecting the proper CPT code for Commercial and Medicare carriers.


The Medicare Part B payment allowance for seasonal flu vaccines are 95% of the average wholesale price.  Patient deductible and coinsurance amounts do not apply for the vaccine.  All providers who administer the vaccine must take assignment on the claim for the vaccine.  The CMS Seasonal Influenza Vaccines Pricing page lists the payment allowances for the 2016-2017 flu season.

Did You Renegotiate Your Payor Contracts to get the Raise You Deserve?

Is it Time to Renegotiate Your Payor Contracts?


There are too many times to count where we’ve encountered physicians who haven’t renegotiated their payor contracts for years and sometimes never.  If you fall into this category then don’t waste another minute.  Don’t miss out on getting paid more for the work you are doing.  Get those contracts out, dust them off and prepare to renegotiate.

The following steps will help you through the renegotiation process and alert you to some key terms that payors don’t want to include in your contract but you should make sure they do.

Contract Review

  1. Study your current contracts and fee schedules
  2. Review contract terms
  3. Know your term and termination language and notification requirements

Do Your Homework

  1. Generate a list of DX codes with frequency for the quarter and the year
    1. This will show you what codes you use;
    2. 20% of the codes are used in 80% of the cases and those are the ones you want to have the higher fees
  2. Know your highest volume CPT
  3. Benchmark reimbursements against the Medicare fee schedule
  4. Prepare and excel spreadsheet listing the top reimbursement and the top highest carrier.
  5. Know your practice model
    1. What makes your practice unique?
    2. Do you have an in-house lab, are you bilingual, do you provide consultations, are you double or triple boarded?  Are there demographic advantages?  Do you provide ancillary services?  These things could get you higher reimbursements.
  6. Make sure you are on ACH for all carriers.  Your billing service should do this for you.

Know what you Expect/Require from the Payor

  1. Do not allow the carrier to just look at your taxonomy number because they might not understand or see the whole picture.
  2. Require the carrier to review your prior utilization
  3. Address the top 25 used ICD-10 codes that you identified when you did your homework
  4. Determine carve-in and carve-out ICD-10 codes.

Key Terms

  1. If you have an evergreen contract (one that renews automatically) then you should have a set percent increase every year.  If it isn’t an evergreen contract you have the right to renegotiate every year.
  2. Claim adjudication should be daily not weekly and make sure this is spelled out.
  3. When they ask for records, make sure the contract spells out the turn-around-time for their review.  It should be 14 days.
  4. The contract should spell out the denials management process, i.e. TAT, appeals.
  5. How are refunds handled?  Take backs should be written out of the contract.
  6. Check and comply with their CAQH and professional liability update requirements.  You must stay updated or the can kick you out for non-compliance.
  7. Understand the language of the contract.

The Proposal

  1. Prepare an impactful proposal letter.  This is a sales pitch.  Most physicians don’t like to think of it as a sales pitch but that is what it is.  Sell yourself and your practice.
  2. Don’t mention pricing at this point
  3. Send your proposal to a specific person, i.e. your network representative.
  4. Track it.  The payor will take approximately 4 weeks to internally evaluate your proposal and do their utilization review.
  5. Follow up.  Call every 15 days.  Don’t be surprised if you get the run-around.  Just hang in there, call and remind them that you have called before and that you are checking on the status.

The Offer

  1. Do not accept the first round of negotiations.  Always counter
  2. Evaluate, compare and decide on next steps.
  3. There will likely be things you like and don’t like but decide what is most important to you and be prepared to compromise.  Both sides should win and lose something.
  4. Is the rate increase retroactive?  If so, to what date?


  1. Before you sign, verify that the contract includes the reimbursement rates, the increases, and all terms.
  2. Sign the contract and return it certified mail.
  3. Tell your billing company.  Your hard work will only pay off if you have good revenue cycle management.  The billing company needs to know
    1. the new fee schedule;
    2. claim adjudication terms;
    3. denial management terms;
    4. turn-around times; and
    5. refund management terms
  4. Track your reimbursements
    1. Check EOBs for the first few months and periodically thereafter to make sure reimbursements are consistent with the new rates.  If you have been underpaid you can rebill for the difference.

Renegotiating payor contracts is time-consuming and can be frustrating but it is so necessary.  You already know that insurance companies aren’t going to look out for you.  You must look out for you so start today and take it one step at a time until you get your raise.


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