All posts by Stephen Brighton

Avoid PQRS Penalties Starting Today

The PQRS Penalties for Not Participating In the PQRS Initiative

The Physician Quality Reporting System (PQRS) is the beginning of CMS’s goal to pay for performance and quality care instead paying fee for service.

Penalties for Not Participating in or Following the Guidelines of PQRS are the Following:

If you did not participate in or follow the guidelines of PQRS in 2014 there is a 2% penalty on each of your claims for 2016

If you did not participate in or follow the guidelines of PQRS 2015 there will be a 2% penalty on each of your claims for 2017

If you do not participate in or follow the guidelines of PQRS in 2016 there will be a 2% penalty on each of your claims for 2018*

*If you are an individual provider and do not participate in PQRS in 2016, the penalty will be 4% on each claim in 2018



Medicare already deducts 2% per claim for sequestration.

PQRS Facts

Within each measure is a group of codes:

  • The PQRS guidelines state that an EP must use nine measures on 50 % of the claims that the EP submits to Medicare within the year 2016.
  • The codes that are submitted must fall into three of the following six domains. Each code has its own designated domain.
  • The six domains are the following:
    1. Personal Caregiver Centered Experience and Outcomes
    2. Patient Safety
    3. Communication and Care Co-ordination
    4. Community Population Health
    5. Efficiency and Cost Reductions
    6. Effective Clinical Care

One of the measures to satisfy the requirements of PQRS participation must be a “cross-cutting” measure.  The list of “cross-cutting” measures may be found at

If Medicare is the secondary insurance, the provider still is obligated to submit the PQRS codes.

When using any of the PQRS codes, the documentation in your notes must match the PQRS code (s) that you submit

Methods of Reporting if you are an Individual Practice

  • Claims reporting
    • Electronic Reporting Using CEHRT (Certified HER Technology) or on paper claims
  • Registry reporting
    • Qualified Clinical Data Registry (QCDR)

Methods of Reporting if you are a Group Practice

  • Registry Reporting and/or Electronic Reporting Using CEHRT (Certified HER Technology)
  • Group Practice Reporting Option (GPRO) via Web Interface (only available for groups of 25+ EPs)
  • CAHPS (Consumer Assistance of Healthcare Providers and Systems) for PQRS via claims survey vendor (for group practices of 2+) to supplement PQRS group practice reporting

Medical Healthcare Solutions is collaborating with Ruth Dolby of Dolby Healthcare Consultants to help practices avoid PQRS penalities in 2016.  Ms. Dolby has in-depth expertise to help providers decide:

  • How the practice will report the PQRS measures
  • Which PQRS codes the practice will be reporting if the practice is reporting the codes on claims


If the practice is reporting the codes on claims, once the PQRS codes are established, Ms. Dolby will advise the practice concerning the guidelines for each code, including for example

  • How often the PQRS code has to be submitted within the reporting period
  • The diagnosis associated with each code, if a diagnosis is applicable, and
  • The age requirements for the code
  • The CPT codes that are mapped to the PQRS codes to be submitted


Please reach out to Medical Healthcare Solutions today to help your practice avoid PQRS Penalties

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Medical Billing Clients

A Physician’s Guide to Revenue Cycle Management

picture of young team or group of doctors

Good practices are not complete without a healthy revenue cycle. However, with the amount of patients received by hospitals and healthcare practices, a system must be established. The system will record every single detail of the patient, regardless of its relevance. In addition, the system will act as a protocol for staff that ensures no details are missed as well as the completion of necessary processes. Once this system is in place, your practice will start to make progress.

While this seems like a difficult task, the benefits heavily outweigh the extra effort. Here are some points that will lead to a stable, and lucrative, practice.

Focus on details.

This may seem like arbitrary advice, however often times it is ignored. Every error made runs the risk of affecting both records and payment collection.

Keep on target.

    Often times when patients come in for one issue, many others get discussed along the way. Be sure to note why the patient initially came in and keep this in mind throughout the visit.

Be knowledgeable about insurance.

This information is extremely important to the visit. A physician must know what type of insurance the patient has, whether or not the visit is covered, and what out-of-pocket expenses could occur from the visit. The more transparent the physician is with the patient, the easier explaining insurance policies becomes.

Collect on time.

Payments that are made on time promote a healthy revenue cycle. Since they are a direct main cash inflow, any late payments can directly impact your revenue cycle. Educating patients about their insurance policies at the time of their admittance is the best way to collect timely payments. Setting up a department solely dedicated to collections will only add to collection timeliness.

Maintain low denial rates.

    Denial rates, no matter how undesirable, will occur. This happens primarily because of improper procedure coding and performing care uncovered by the patient’s network. Unfortunately, only about 30% of patients make sure they are eligible for the procedure before they are admitted. Paying closer attention to initial coding and, again, in-depth knowledge of insurance policies are the best ways to reduce denial rates.

Ensuring Proper Reimbursements.

    Since insurance companies try to pay out as little as they can, you must have a proper system established in order to receive all the money you are owed.

Collecting Co-Payments.

    The amount of money the patient will owe (as discussed in their insurance’s co-payment terms) needs to be clarified before admittance. This ensures there will be no discrepancy between the patient and the practice and co-payments can be immediately collected.

Be sure to Pre-authorize necessary treatments.

    There are cases where procedures need to be completed even if they aren’t covered by insurance. By pre-authorizing treatments, you are reducing your denial rates and ensuring more reimbursements while helping the patient.

Of course, these points are a way to guide you to a better practice. Keep in mind that every practice has its own specific needs. Many practices struggle with a variety of problems. Having difficulties along the way is natural and bound to happen. To ensure an improvement, your practice must be consistent and dedicated to change.  As long as you are paying close attention and avoiding careless mistakes, your practice will see progress.


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ICD-10 Changes Are Coming: What You Can Do to Be Prepared

ICD-10 ChangesThe ICD-10 release date is fast approaching. October first will be here before we know it. However, there is still plenty of time to prepare for this enormous change. To make the adjustment as smooth as possible for you and your employees, there are some steps your practice can take now in preparation.

Train Now

            The best thing you can do to prepare is to make sure your staff understands ICD-10. The sooner you start training them, the sooner they will begin to understand the new system.   All members need to be on board with this, as this is an extremely large change. There are plenty of programs and classes you can purchase that will help train your practice for the impending changes, or you can choose to learn the coding yourself and relay that information to your employees.

Learn the Most Important Codes

            With ICD-9, many practitioners have all of the codes memorized because of the frequency in which they use them. Because of its complexity, ICD-10 will be more difficult to memorize. The codes have 5-7 digits per code, an increase from the current 3-5. Prioritizing codes that will be used frequently makes the task of memorizing them a lot less daunting. It is important to pay attention to what codes are used more often than others and make sure you have those down. The sooner you begin working on memorizing common codes, the easier the transition will be.

Build a Communication Team

Strong communication is what will make the transition smooth and manageable. To ensure that your practice has open lines of communication, you’ll need to build a communication team. A project manager needs to be established. This person will need to be the resident expert of the system and be able to answer any questions that arise. They’ll also need to have a contact person outside the office who fully understands and has mastered the program. Having many people who have a strong understanding of ICD-10 can only help everyone get onboard with the transition.

There are many ways to prep for ICD-10. The more time you spend preparing for ICD-10 before it is enforced will mean the less time you spend struggling to understand it later on. This is a great advancement for the medical field and can only get better.

What steps is your practice taking to prepare for the upcoming ICD-10 changes?

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Preparing for the Next Wave of Medical Billing Changes

Stethoscope on medical billing statement on table

Today’s rapid technological evolution allows new solutions for old problems to be made every day. Many changes are constantly being made to all industries. This includes the medical industry, which is continuously evolving. Over the next decade, it is predicted that many people will self-diagnose more often due to increased amount of information available on the internet. While there is the possibility that this could lead to less patients, there are ways to combat this.


Keep up with latest billing strategies

There are many medical billing strategies that are on the rise in today’s medical field. One of which is becoming popular is the smartphone app Fee Schedule Pro. It is an app that allows patients to take care of their medical payments through the app. Different apps like this one are being created as it is predicted that more and more payments will be handled electronically. Another upcoming innovation that is being created is a universal software that will allow you to bill plans automatically regardless of billing type form. It will eliminate any confusion from making sure all payments are up to date.

Be efficient and effective

A great way to retain patients and make sure they have a pleasant experience at your office is to make sure that they can handle their outstanding balances very easy. This is imperative because as a result of the increase in self-diagnosis, there will also be a rise in cost of medical care and treatments to make up for the loss of patients. This is merely a prediction but should be taken seriously. Patients will be more apt to continue to get medical treatment at a higher rate as long as paying for it is an easy process.

Welcome change

It is inevitable that things in all aspects of the world will change over the next decade, there is no denying it. Whether or not you prepare yourself for those changes can either make or break how your practice does while weathering the storm. Updates in technology can sometimes be stressful and scary, but it is truly a beautiful thing. It allows patients and doctors to have an easier time finding out what’s wrong, which can lead to a speedier recovery. Most importantly, however, all these changes allow for patients to live a healthier, happier life.

Want to learn more about Medical Billing or have a comment? You can find more on our blog at

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Medical Billing

What To Look For In A Medical Billing Company

A medical billing company may be exactly what your practice needs to handle the many non-medical obligations it will inevitably face. These companies can reduce your overhead by taking care of things such as billing, coding and collections. Hiring a medical billing company is essentially outsourcing much of your practice’s work, and as useful as that can be it can also cost your practice a lot of money if you don’t ask the right questions before making any final decisions.

There are a lot of medical billing services out there, and not all of them are created equal. Billing and coding are major elements of a healthcare practice, so it’s important that you ask the following questions to make sure you’re hiring the best company for your practice’s needs.

What Will the Service Cost and What is the Average Time for Receivables?

The cost of a billing company’s services should be first and foremost on your mind. Ideally, you should be paying a percentage of all net collected receipts where permitted. Look for a company that charges six percent or less of net collected receipts; any higher is probably too high for your practice. You should also be asking about any additional charges; billing companies can charge fees for startup, termination, data conversion and patient collections.

The average time for receivables is an important factor when choosing a medical billing company. Choose a billing company that processes receivables between 14 to 30 days depending on payer rules.

A Good Medical Billing Company Should Reduce Administrator Tasks.

When evaluating a billing company, ask what types of code edits and payer rules they use. A good billing company will check for accuracy, coding and correct payment. If a claim is denied ask how the claims get fixed and how long it takes to process denied claims.

Is the Company Versed in More than One Practice Management System?

Different medical practices will obviously use different management systems, and it stands to reason that you will want to find a medical billing company that is well-versed in your practice’s management system. Some of the more reliable systems include Allscripts, Athenahealth, Cerner, eClinical, EPIC, GE Centricity and IDX. These are fairly common, and any company that is familiar with these systems should provide excellent and reliable service.

Can They Provide References?

Reputation is important for any kind of company, including a medical billing service. Ask what kinds of practices the company has worked with in the past; they should be similar to you in size, scope and specialty. Don’t be afraid to ask for testimonials from satisfied clients or for people you can call directly.

Are They HIPAA-Compliant?

Any organization that deals directly with patient’s confidential medical information must comply with the federal Health Insurance Portability and Accountability Act, or HIPAA. That of course includes medical billing companies. Any company that is HIPAA-compliant will be proud to answer any questions you might have so be sure to ask.

Who Will be Handling Your Account?

You should know exactly who will be handling your account within the billing company. See if you can speak to the person or people who will be in charge of your data. A reputable billing company will be straightforward and transparent when it comes to this information.

Does the Medical Billing Company Offer Consultation for ‘Meaningful Use’?

Meaningful Use means being able to correctly demonstrate how an Electronic Health Record or EHR will be used based on certain government-set criteria. A good medical billing company will be able to provide consultation about Meaningful Use if your practice uses an EHR regularly, and they will be up-front about how they will use these records themselves.

Are There Services They Will Not Handle?

Never assume that a medical billing company will take care of all billing and coding duties. There may be some items that are not included in their services, or some that are only included with an extra fee. Clarifying these issues in the beginning will help you plan ahead and either find a different billing service or hire employees to handle certain tasks in-house.

Can They Guarantee Transparency?

As we said before, a reputable medical billing company will be up-front and transparent with all of their data and services. You should be able to receive accurate and timely reports about your practice’s finances. It is your practice after all, and you deserve to know about anything that is related to it even if it is technically outside of your area of expertise.

If you are interested in learning more about the medical billing services provided by Medical Healthcare Solutions please contact us online or by calling Stephen Brighton or Sandy Dallon at 800-762-9800.


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