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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change is garnering attention because it’s the first final rule issued since the sustainable growth rate formula was repealed by the by the Medicare Access and CHIP Reauthorization Act of 2015.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

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2016 Medical Claims Processing… Who Determines the “Value” of Value-Based Payments?

With all the discussion around value-based payments and quality-incentive programs newly instituted by Medicare, one begs to question…who decides what’s quality? How do we know that what’s considered value to one is legitimately valuable to everyone?

Of course the answer to both questions is relative. In terms of medical care (and most everything else for that matter) it’s hard to define what “quality” really means. Our hats are off to CMS for at least attempting to define it and for trying to incentivize physicians, practitioners and facilities for value over volume. Though it seems like a nightmare in terms of submitting medical claims, the end goal is to increase the quality and efficiency of medical care, and that’s a win for everyone.

Here’s how they’re doing it…

The value-based payment program is comprised of two basic components. The first is the Quality and Resource Use Report (QRUR), which is basically a confidential report about both the cost and quality of care provided to Medicare patients. Secondly, there’s a Value-Based Payment Modifer (VBPM) or “score sheet” that adjusts payments up or down according to the results of the QRUR.

Thankfully, for those of us in medical claims, payment adjustments don’t happen in real time. It would be incredible if rates were charged according to the actual care given at any particular office visit or during a particular procedure, but we aren’t there quite yet. In 2015 CMS started applying the new score sheet to a select group of physicians, all based on performance data collected from their patients back in 2013. And that’s how things will continue. In 2016, the Value Modifier will be applied a specific group of physicians, based on performance in 2014.

For more information on value-based payments visit the CMS website at

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Free Fact Sheets: Common ICD-9-CM Codes and Possible ICD-10-CM Equivalents

Free Fact Sheets: Common ICD-9-CM Codes and Possible ICD-10-CM Equivalents

The ICD-10 deadline is here and Apex EDI realizes that you may need additional resources to help make the transition smooth. We have compiled three fact sheets identifying commonly used ICD-9-CM codes and matching them with their possible ICD-10-CM equivalents, one sheet for General Medicine codes, one for Ophthalmology codes, and one for Chiropractic codes.


Please note this tool is not designed to provide perfect matches between the two coding systems. In fact, except for a minority of cases, perfect matches between the ICD-9-CM and ICD-10-CM coding systems do not exist. Given the significant increase in detail and specificity in the ICD-10-CM coding system, in most cases there is no direct match between ICD-9 and ICD-10 codes. A clinical analysis is required to determine which code or codes should be used. It is important to remember that even when there is only one ICD-10 code, it is not necessarily completely equivalent to the source ICD-9 code. This tool is not designed to replace proper training and documentation.

Proper coding begins with the doctor and documentation. While Medicare Part B is not going to deny claims based solely on the specificity of the ICD-10 diagnosis code as long as the codes are from the right family, they may pay less than what they have paid in the past based on the specificity of the diagnosis code. These tools are meant to shorten the amount of time spent looking up codes for best specificity. Most of the conversions identify the family where the appropriate crosswalk can be found. In the rare occasions where there is a direct crosswalk a clinical analysis is still required to determine if the crosswalk is appropriate for the billing situation.

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Medical Claims Clearinghouse

With all the regulation changes that have happened and have yet to happen, navigating the healthcare revenue cycle can be overwhelming. So much of what physicians do is overseen by one regulatory committee or another. In fact, often it is multiple committees that oversee one aspect of healthcare. Understanding what the healthcare professional needs to comply with can be costly. That is why having a medical claims clearinghouse on your side is a powerful partnership that no healthcare practice should be without.

In 2010 congress passed the Affordable Care Act (ACA). This law put into place numerous regulation changes. Some of those changes were obvious, like increased patients with insurance, others were not so obvious, such as insurance companies providing administrative and financial transactions that are compliant with the standards set forth. A medical claims clearinghouse is there to help manage these changes on behalf of the physician. They can help physicians by cutting through overwhelming documentation and let them know what they need to act on. They also maintain the relationship with the insurance company when it comes to the electronic interchange of data. This allows the medical claims clearinghouse to advocate for the provider when it comes to establishing connections for the administrative and financial transactions the insurance companies are now required to provide physicians. These transactions include, but are not limited to, electronic eligibility and benefit verification and electronic explanation of benefits (EOB’s).

With the ACA a number of regulatory bodies became prominent in the healthcare industry. One of those bodies is the CAQH body. They are responsible for the CORE operating rules. CORE operating rules are mandated operating rules in section 1104 of the ACA. The purpose of these operating rules is to:

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Apex EDI (Electronic Claims Processing) Integrates with My Vision Express Software

My Vision Express logo

(Salt Lake City, UT) March 28, 2014 — Apex EDI, is proud to announce their integration with My Vision Express (MVE) Electronic Health Records and Practice Management Software for Eye Care Professionals (ECPs), for electronic claims processing. More details will be released in the official press release March 28th at the Vision Expo East International Ophthalmic event.

This powerful integration allows MVE users to “click” and send claims electronically to Apex EDI, directly from their software. The interface also features an insurance portal to verify patients’ eligibility at the time of service verify claims status, and view and fix claim errors. Additionally, Apex and MVE are focused on facilitating ECPs efforts to meet the requirements of the ICD10 and EMR/meaningful use requirements. These new features will assist ECPs to reduce their accounts receivable and streamline claims management, enabling them to focus on providing patient care.

“We are excited to provide Apex EDI insurance clearinghouse services with our software,” said Vipul Katyal, President, My Vision Express. “Together we are providing better solutions that provide exceptional value to the eye care industry!”

“My Vision Express software continues to demonstrate the power of innovative software. We are excited to offer our services as part of their integrated solution to optometry providers,” said Sheldon Miner, Chief Executive Officer of Apex EDI.


Apex EDI is a leading healthcare claims clearinghouse for medical and optometric professionals. Apex EDI serves thousands of physicians, optometrists, and other medical providers nationwide with its Apex OneTouch® solution. The OneTouch® solution is a Web-based electronic claims reimbursement system that increases productivity and profitability while facilitating fast payment of insurance claims and providing additional reporting and analysis. For more information about APEX EDI, visit: (800 840-9152)

About My Vision Express

My Vision Express was designed exclusively for optometrists, ophthalmologist, and opticians who want to boost the efficiency and growth of their practices. My Vision Express features a comprehensive EHR, innovative POS, and many powerful inventory, business, marketing, and staff management tools and attest for Meaningful Use Stages 1 and 2.

Multiple licensing options are available with My Vision Express, from single computer users to multiple computer users across multiple locations, so there is a solution for every type of practice. My Vision Express is easily accessible on the devices you currently own – Windows, Macs, iPhone, iPad, Android, and Kindle – enabling you to manage your practice from anywhere and is available as both Cloud and in-office server solutions.

My Vision Express offers a free 30-day trial of the software. Contact 1-877-882-7455 or visit for more information.

My Vision Express
3050 Universal Blvd, Suite 120 – Weston, FL 33331
1.877.882.7455 –

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