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Things You Should Know About Submitting Dental Claims

While medical claims billing can be complicated, submitting dental claims is an entirely different beast. Before you submit any dental claims, be sure to educate yourself and your practitioners about the do’s and don’ts of dental claims billing.

Paper or E-File?

Do you stdentist 1ill submit claims for your dental practice through snail mail? It might be in your best interest to consider updating your practice to include electronic filing. Electronic filing processes claims more quickly and efficiently than traditional postal service submission. Even if you currently incorporate electronic filing at your practice, some payers may still require paper submissions. In this case, be sure to keep an electronic record of all dental claims submissions to payers who require paper claims.

If you’re interested in incorporating electronic filing into your dental practice, check out our Dental Claims page for more information about seamlessly integrating this software with your existing dental practice management software.

Are X-Rays Needed?

050803-N-1126D-004 Jacksonville, Fla. (Aug. 3, 2005) - Dental Technician 3rd Class Jose Sanchez prepares a patient for dental X-Rays at the Naval Hospital on board Naval Air Station Jacksonville, Fla. U.S. Navy photo by Photographer's Mate 3rd Class Clarck Desire (RELEASED)

As a dental practitioner, you know that some claims require x-rays in order to be properly processed. Common claims that require x-rays include restorative practices such as crowns, implant supported prosthetics, and fixed partial denture retainers, to name a few.

With Apex EDI, you’ll know exactly which claims will require x-rays for proper submission and processing. Apex OneTouch, the desktop application, will notify your claims professionals of failed claim submissions due to missing items or mistyped information.

Best Practices for Patient Education

Before submitting any dental claims, it is important to educate the patient about the claims process. Your practice may differ from another dental practice in claims submission. It is important to educate the patient about the difference between in- and out-of-network providers, as well as providers that are not accepted at your dental practice, as well as the typical process of claims submission.

This may include the length of time required to process a claim, and how your practice will contact the patient if there is any out-of-pocket expenses required on their part as per their dental insurance provider. By educating the patient about your dental clinic’s best practices, you are hopefully preventing any miscommunication or misleading practices that could cause patient dissatisfaction or overdue accounts.

In order to put your best foot forward in your dental practice, be sure to check out our Dental Claims page for more information about how we at Apex EDI can simplify dental claims submissions for you.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

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The Number One Medical Claims Billing Problem

As a healthcare provider, it’s safe to say that you have had your fair share of medical claims billing problems. However, one problem seems to stand out above the rest. That problem being billing disputes.

041019-N-5821P-019 Yokosuka, Japan (Oct. 19, 2004) - Airman Lauren Thurgood of Las Vegas, Nev., pulls patient medical records in the inpatient ward aboard the conventionally powered aircraft carrier USS Kitty Hawk. Kitty Hawk's medical department services between 80 and 100 patients daily, providing around the clock, quality health care. Currently in port in Yokosuka, Japan, Kitty Hawk demonstrates power projection and sea control as the U.S. Navy's only forward-deployed aircraft carrier. U.S. Navy photo by Photographer's Mate 3rd Class Jason T. Poplin (RELEASED)

Billing disputes can occur for a variety of reasons.

Perhaps a billing code was entered incorrectly or maybe a claim was denied for not being a covered service through an out-of-network payer. Or perhaps a claim was denied due to the patient not yet meeting their own out-of-pocket deductible. Regardless of the reason, billing disputes are a hassle for you as the provider and for the patient expecting the service to be covered by their insurance.

What is the solution to this claims nuisance? The solution is to implement a medical claims billing software that partners with your existing practice management software to ensure cohesive and credible claims billing within your healthcare practice.

Apex EDI is the software you have been waiting for. Apex EDI partners with your existing practice management software to provide seamless medical claims billing. Apex EDI verifies medical claims before they are submitted to the payer in order to ensure correct billings and payments to you, the healthcare provider.

By partnering with more than 30 practice management software systems, Apex EDI implements a complete integration that allows your existing software to plug and play into our desktop app, Apex OneTouch. Apex OneTouch allows you to submit claims electronically, verify patient eligibility in real time, as well as review claim history and send and organize claims with custom fields. The Apex EDI system also maximized patient security through secure portals that uphold patient privacy and HIPPA practices.

Apex EDI works to process medical billing claims faster, so that you can focus on providing exceptional healthcare to your patients.  For more information or to review plans and pricing, be sure to contact us with your questions or to sign up for Apex EDI.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

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Understanding Medicare’s Role in Advance Care Planning. Five Questions Medical Billing Companies Need to Know.

As a follow-up to our recent article on the 2016 Medicare regulation change that allows physicians to bill for advance care discussions, we thought we’d share a few pertinent details on what “advance care” really means. Though doctors have some leeway to cover what they think is best, the more medical billing companies know, the better they can protect their clients.

Everything from updating patient management software to health insurance claims processing can be affected by the change – here’s a primer on advanced care terms and technicalities.

As a Matter of Fact…

  • ¾ of the 2.5 million Americans who pass away each year are 65 and older.
  • Medicare is the largest health insurance provider for Americans in their last year of life.
  • ¼ of all Medicare health care coverage is spent on beneficiaries in their last 12 months of life.
  • 90 percent of aging adults report that they’d prefer to die at home, though historically only 1/3 actually do.

What is “end-of-life care” exactly?

In simple terms, end-of-life care includes all the services provided for patients in the days (or even years) prior to their death. Medicare covers a comprehensive list of end-of-life health care services, including hospital stays, diagnostic testing, physician visits, home health care, prescriptions, and so forth. Though a patient’s prognosis may be “terminal”, end-of-life services can be intended to either cure conditions or simply provide symptom relief.

What does “advance care planning” entail?

The goal of advance care planning is to help patients and their family members/caregivers better understand all the care options available for them at the end of their lives. Typically, physicians will discuss the various options available (curative treatments, pain management options, at-home care or in-hospital stays for example), make recommendations on a treatment plan, then help the patient to determine which options best align with their individual desires. (In terms of billing for claims processing software, there are two codes to cover these conversations. The first covers the first 30 minutes of discussion – which may be all a patient needs. There is an additional code that covers additional 30 minute conversations as necessary.)

Are physicians the only Medicare-approved resources for advance care discussions?

No. Under the new regulation, Medicare covers advance care planning discussions provided by physicians and other health professionals, such as nurse practitioners, who bill Medicare according to the official physician fee schedule. Discussions should take place in medical offices and approved facilities and hospitals, and can be part of an annual check-ups or wellness visit. (Note for health insurance claims processing: Medicare should be billed separately for advance care.)

What are “advance directives” and in terms of patient management software, are facilities required to keep records of them?

In essence, advance directives are written instructions that define a patient’s wishes for end-of-life care. They become invaluable in instances where a patient is incapacitated or is no longer able to speak for themselves. They are often referred to as a “living will” and typically result from advance care planning discussions. Advance directives define specifically the medical treatments and types of treatments each patient prefers as they are nearing dying.

Advance directives fall under state regulations. Official forms for directives vary from state to state as do the requirements for documentation. Though patients are not required to have one, the Patient Self-Determination Act of 1991 requires that hospitals, skilled nursing facilities, etc. ask each patient if they have an advance directive at the time of admission.

What is “palliative care” and is it covered by Medicare?

As opposed to services intended to cure or treat a specific illness, palliative care generally focuses on managing symptoms and providing comfort to patients nearing the end of life. (Although palliative care is most common for patients receiving end-of-life care, it is not restricted to those with terminal illnesses. It’s also very common for people living with serious chronic illnesses including cancer, heart disease and depression.) In terms of health insurance claims processing, Medicare beneficiaries can claim coverage for palliative care services whether they are offered in combination with curative treatments or not.

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Turns Out Advance Care Planning Is Worthy; Medicare now Covers End-of-Life Conversations. Is Your Medical Claims Billing Software Ready?

The discussion around paying doctors for helping patients with advance care, or end-of-life planning, isn’t a new one, but it finally got traction in 2015. After years of debate around the issue and countless conversations about whether reimbursing physicians for their time consulting the terminally ill is worthy, at the stroke of midnight on January 31, the country decided it finally is.

It’s difficult to talk about death. And difficult for doctors to tell their patients (and their patients’ loving families) that there’s really is no way to avoid it. In America we pull out all the stops to prolong life and pride ourselves on doing “everything we can” to keep folks alive. The reality, however, is that people die every day and the majority of people facing terminal illness don’t necessarily want to exhaust every medical option available. Most want to live out their final days free of pain, in relative peace and with the people they love.

Hence the advance care payment debate. Do we force the difficult conversations?

The government’s first attempt to reimburse for end-of-life planning occurred in the summer of 2009. The proposal was met with swift and furious opposition and so it was tabled until the winter of 2010. That year the administration quietly included the new benefit in a list of regulations that determined the value of various procedures for Medicare. It was a softer approach, but when the inclusion finally made the news, skepticism set in and the attempt was again abandoned. Why? It wasn’t that anyone felt doctors shouldn’t be paid for providing sound medical advice; it was that some considered it an example of the government’s intrusion into health care.

What was the catalyst for change?

In 2012 the medical community joined the conversation. At the meeting of the Illinois State Medical Society that year, several doctors proposed a resolution to ask the American Medical Society to create a billing code for advance care planning discussions. (The AMA creates all the medical billing codes for Medicare. The government regulates how much to reimburse for them.) The doctors based their request on their personal, clinical experience and with that, the AMA agreed. They created 2 new codes and finally, in early July 2015, Medicare published plans to pay for them.

Why should medical billing companies care that such a change has taken place?

Dying is expensive. According to research, the 6% of Medicare patients who die each year account for up to 30% of the program’s annual spend on health care. That means nearly a third of the Medicare’s resources are invested on the dying – and for many of them, the care doesn’t change the outcome. Medicare spent an average of $33,500 on recipients who passed away in 2011 — four times the amount it spent on the recipients who lived.

And in more practical ways, we need to ensure our medical claims billing software can manage the changes. Here’s what you need to know.

In the final ruling on the issue, published late in 2014, the Centers for Medicare and Medicaid Services established the two CPT codes for physicians to document advance care planning conversations. The first covers the initial 30 minutes of discussion. The second is an add-on code for additional 30 minute conversations.

The new codes went into effect for services provided on or after January 1, 2016 and are billable under Medicare Part B. Medical billing companies should be aware (as should administrative and billing staff) that these codes can be used by any physician or non-physician practitioner who bills Part B for their services. Palliative service providers can also bill for advance care planning while most hospice physicians will not.

The conversations included in paid discussions should cover patient goals for care and outcome, specific wishes in terms of advance care, and instruction on advance directives which are necessary for patients, family caregivers and professionals providing terminal care to understand and agree to.

Does your medical claims billing software help keep you compliant in terms of policy changes like this one? Apex EDI’s OneTouch® electronic healthcare claims processing certainly does. Ask us why we’re one of the top-rated medical billing companies in the industry.

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2016 Healthcare Claims Processing

Medicare Regulations Are Changing Come 2016. Apex EDI’s OneTouch® Healthcare Claims Processing Service Makes Change Easy

With the advent of 2016 just around the corner, we’re sure many of you are already aware of the coming Medicare Physician Fee Schedule (MPFS) regulation update this January. If not, here’s a quick look at just a few of the policies that will be affected by the new 2016 payment rules:

    Home Health Value-Based Purchasing

    Driven by mandates in the Affordable Care Act, Value-Based Purchasing incentivizes providers to increase the quality of their care. In fact, the amount of incentives participating agencies receive is directly proportional to the quality scores they earn. The program has been piloted through various disciplines within the medical industry, and beginning January 1, all Medicare-certified home health agencies operating in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee will move to a Value- Based model.

    The “Two-Midnight” Rule

    After considerable debate, the controversial “Two-Midnight” Rule CMS first introduced in 2013 will officially go into effect. In essence the rule clarifies that in terms of Medicare payments auditors must assume a hospital stay was legitimate and necessary as long as the stay spanned two midnights. (Stays under the two-midnight mandate will now be billed as outpatient observation care; a key difference in terms of healthcare claims processing.) According to CMS, this illustrates the “long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries.”

    End-Stage Renal Disease Quality Incentive Program

    Like the Value-Based Purchasing initiative discussed above, the new End-Stage Renal Disease rule will tie the incentives dialysis facilities receive to the quality of the dialysis care their patients actually receive. Quality of care will be determined with respect to measures such as infection rates, safety violations and overall patient experience. In fact, facilities that fail to meet a “total minimum performance” requirement will be penalized with a reduction in their rates.

    New Physician Payment System

    This change is garnering attention because it’s the first final rule issued since the sustainable growth rate formula was repealed by the by the Medicare Access and CHIP Reauthorization Act of 2015. The new rule covers quite a bit of ground, but most notably, also begins a new period of physicians and practitioners being paid according to merit. Like many other agencies, physicians will receive payment incentives for providing high-quality, while those who fail to meet standards may be subject to payment reductions. Also included is the institution of two new, separate billing codes for advance care planning services provided to Medicare beneficiaries. Formerly all advanced care planning has been coded under a single “Welcome to Medicare” visit. This change allows for Medicare coverage of more in-depth discussions.

While regulation change can seem confusing, rest assured that with Apex EDI’s OneTouch® electronic healthcare claims processing, we’ve done the heavy lifting. In all the ways possible, our real-time eligibility verification, patient statements delivery, and electronic remittance advice (ERA) will take regulation changes into account— ensuring that the process for collecting payments come January 1 is as simple and secure as always.

For more information on the 2016 regulation changes visit https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-2.html.

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