A question I’m often asked is, “Why do physicians charge so much?” There’s no easy answer, as there isn’t a fixed price list for medical services. Due to the healthcare system’s complexity and the absence of set prices, providers are largely free to charge what the market will bear.

However, can there be consequences for over-pricing or egregiously overcharging payers? Yes. It’s crucial to pay close attention to this issue, as it could lead to trouble not only legally but also in terms of regulatory compliance.

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The post Can physicians charge whatever they want to Insurance Payers? appeared first on Terry Fletcher Consulting, Inc..

Engaging with “bad actors” in medical billing can have serious consequences for both patients and healthcare providers. More and more providers are engaging without checking. Here’s what could happen. Terry discusses it all with examples.

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In this episode, Terry challenges all medical professionals. What is your role in managing the patient experience?

A lack of patient prep can lead to an incomplete encounter for the physician including excessive visits. It can also lead to leakage in all departments, including the RCM staff’s ability to perform their job.

Terry offers her tips for accountability in all departments, starting with scheduling, to ensure the provider is “prepared” to see the patient.

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Since the implementation of the No Surprises Act (NSA) in January 2022, out-of-network (OON) reimbursement has become a complex and resource-heavy challenge for hospital and health system revenue cycle leaders.

Although designed to shield patients from unexpected medical bills, the legislation has placed continuous financial pressure on physician practices and hospital systems. It has led to delayed payments, operational burdens, and strained resources.

In this episode of the CodeCast Podcast, Terry runs through how the NSA works not only for your RCM staff but also how she dealt with a personal “balance bill” for the win!

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Medical necessity is defined as services that are reasonable and necessary for diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Unfortunately, we have many practices trying to slide under the radar the experimental and/or investigational services that are considered not medically necessary or a covered benefit under most payers. Terry discusses the ins and outs of this practices and how to make sure you are not falling into a false claim trap.

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Terry discusses Behavioral Health services, best practices documentation and coding specifics. Also, Terry offers some bonus discussion on RAC auditors trying to bait providers into not responding to ADR requests.

Check out this episode for intel on these important topics and more.

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With all of the AI implementation into EHR and EMR systems, there is concern about how providers rely on these AI shortcuts more than ever. Without proper safeguards, accountability, and compliance perimeters, relying on AI could be problematic.

Terry discusses the red flags to look for and how to proceed with caution in this new world of technology.

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The post Did you know AI is integrated into EMRs? appeared first on Terry Fletcher Consulting, Inc..

The 2023 CPT® Errata and Technical Corrections added a one-liner on Independent Interpretations that responds to the question, “Can a practitioner get credit for both ordering and interpretation of a test, if documented?”

In this episode of the CodeCast podcast, Terry answers this question referencing the March 2023 CPT® Errata and Technical Corrections. She also covers the reality of this change and what an independent interpretation means, so that you are not upcoding based on assumptions.

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The post Can you get credit for ordering and interpretation of a test? appeared first on Terry Fletcher Consulting, Inc..

The 2021/2023 E/M guideline revisions read: “The evaluation and/or treatment should be consistent with the likely nature of the condition.” Before this, the CPT® guidelines did not discuss medical necessity. Guidance was left to the payers, particularly Medicare, via the Social Security Act.

CMS’s guidance doesn’t necessarily hold regulatory authority. However, it often reflects a new, shared understanding that medical services reported should meet documentation standards for level selection. Those standards should also appropriately indicate why the patient is visiting the provider, based on the presenting problems.

This episode of the CodeCast echoes Terry’s insights that auditors, coders, and medical professionals focus on medical necessity first, then look to coding.

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The post Medical Necessity Comes Before Coding appeared first on Terry Fletcher Consulting, Inc..

It’s time for another round of frequently asked questions as Terry’s expertise covers orthopedic surgery, imaging, data points for E/M, and administrative charges for practices.

She also answers questions relating to multiple E/Ms on the same date by the same and different physicians from the same group practice.

Tune in for a lot of good information covered on this week’s show.

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The post Top 10 Tuesday Q&A – Coding, Billing, and Compliance Questions appeared first on Terry Fletcher Consulting, Inc..