Posted in In The Know Series, Insurance, My services, Payers and CPT reinbursement

Does more GHI patients = more revenue? Year 2018

In recent 2 months or so, I have seen an influx of GHI patients coming to my practice.

Great for business, right?….Well it depends on your preference and financial stability of your practice.

Let me Explain.

In the last year In Network Providers have noticed an increase in “Patient Financial Responsibility” and substantial reductions in payments for certain allergy and immunology CPT codes and/or EM codes.

For Example: CPT code like 99213 carries a $30 co-pay and payment of $17 to the provider or no co-pay and a payment of $40 or co-pay of $10 and a payment of $37 to the provider, or co-pay of $30 and a payment of $24 to the provider.

CPT code 94200- carries a $20 co-pay with no payment at all and a co-pay of $22 for CPT code 95117 with no additional payment.

Respectively lower payments compare to other payers.

Providers started to notice this trend and slowly but surely some of them started to either stop accepting new GHI patients or completely stop accepting GHI insurance all together, like ENT.

So should you accept more GHI patients? Well, it is up to you.

I personally created a specific form for GHI patients- informing them of new changes and their new Patient Financial Responsibilities. I let the patients have options to either choose to perform certain services and pay respective co-pay or opt out completely.

Now it is your turn: have you seen an increased amount of GHI patients in your practice? Do you even accept GHI?

Posted in Insurance, Payers and CPT reinbursement

1199 payer and cpt code 95012

Have a lot of asthma patients?…Then this post is for you.

CPT code for NIOX testing is 95012

NIOX is a common test that Pulmonologists and Allergists/Immunologists administer to Asthma patients.

However, the reimbursement for this code veries from payer to payer.

In this post we are lookong at 1199 which only pays for Two (2) 95012 codes, perfomed in a calendar year.

Do you have a lot of denials from 1199 for (limit met)?… check out how many of 95012 you performed for that patient, per calendar year.

If you have any other questions, about this payer or any other, please feel free to contact me for a free GAP Analysis- valid 9/1/2017 to 12/31/2017.

Posted in Insurance, Payers and CPT reinbursement, Training

Flu vaccine and provider reimbursement for Medicaid, MC and Child Health Plus patients (for NY State)

The flu season is upon us and many providers would like to bill for administering the flu vaccine. Unfortunately, not all providers will get reimbursed.

Once the provider administers the flu vaccine and starts to enter it into the EHR (ex. Practice Fusion), there is a VFC qualifier that the provider needs to answer.

So, now let’s look at what VFC is?

Vaccines for Children Program: federally funded program that provides vaccines at no cost for children who might not be able to pay for a vaccine.

Who qualifies: Any child under the 18 years of age, underinsured, and uninsured patients.  If you see Medicaid, Managed Care or Child Health Plus patients, then those would be the ones that qualify for the VFC. If you see any of those patients, provider should check the box and say YES in the EHR (or select YES, in Practice Fusion)

What does this mean for the providers?

If you are a provider that is located in Public health Clinic, Federally Qualified Health Center, or Rural Health Clinic and are enrolled in the VFC program; you qualify to receive the a reimbursement max and receive the vaccine free of charge from the federal government. The following are the 2017 rates:

– Medicaid Fee-for-Service- $17.85

-Medicaid Managed care- as per contractual agreement

-CHP-as per contractual agreement

– Uninsured $25.10

-Underinsured- $25.10

-American Indian/Alaskan Native- $25.10

However, If you are independent provider that is not enrolled into the VFC program (ex. specialist); bought your own vaccine – you will be reimbursed for administration of the vaccine ONLY for adults. No less than 2017-2018 CMS rates that can be found on their website: Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html