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January 2022

Happy New Year to all our clients! We hope that this year has gotten off to a good start with a renewed focus on coding compliance and revenue integrity. At the time of publication, HHS had just HHS renewed the COVID-19 public health emergency for another 90 days effective January 16, 2022. There will surely be challenges ahead, but now is the time to chart a course for success and stick to it. Physician Practice Resources can help.


This month, we’ve compiled seven news stories to help providers stay abreast of industry developments. As we look ahead, what are your concerns, and how can Physician Practice Resources help? Email us at info@ppr-corp.com. Most importantly, stay safe out there.


Claim denials: Two surgeons sue UnitedHealth and Aetna for underpayments

Two surgeons recently sued UnitedHealth and Aetna over claim denials and underpayments for advanced endometriosis treatment. Among the allegations? That Aetna provided only $1,341 in reimbursement for a nearly $220,000 endometriosis treatment surgery and that UnitedHealth only reimbursed about $3,900 of a $278,000 procedure. It will be interesting to see how this lawsuit pans out.


Telehealth update: Laws and requirements continue to evolve

State telehealth laws and payer requirements are constantly in flux, necessitating the need for someone within the practice to monitor the changes. Want to know where your state stands in terms of legislative flexibilities for telehealth? Check out this new report that provides a state-by-state comparison. Don’t sit back and assume nothing has changed. That’s how denials and recoupments can happen!


No Surprises Act: Prepare your medical practice using this AMA toolkit

The American Medical Association (AMA) has provided a 20-page toolkit that answers common questions about the No Surprises Act and can help medical practices navigate this complex regulation. It’s a must-read for practice managers—particularly the section on good faith estimates for self-pay and uninsured patients.


Principal care management: Leverage new codes that took effect January 1, 2022

Did you know that four CPT codes for principal care management (PCM) took effect January 1, 2022? These codes (i.e., 99424-99427) may be billed when patients require medical or psychological services due to a single, complex chronic condition expected to last at least three months. This article from the American Medical Association reminds physicians to differentiate between PCM, chronic care management (CCM), and complex CCM.


False Claims Act: Focus on medical necessity, documentation integrity to avoid allegations of fraud

One Iowa-based physician group recently agreed to pay more than $600,000 to resolve allegations it violated the False Claims Act as a result of billing Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program for medically unnecessary procedures and for procedures in excess of those actually performed. The specific allegations stated the one surgeon falsely billed various cosmetic procedures as medically necessary. The allegations also stated the surgeon also did not perform services sufficient to bill for high-value office visits that require a comprehensive exam, comprehensive history, and moderate or highly complex medical decision making. The takeaway? Documentation is paramount. This includes medical necessity, patient complexity, and services rendered.


The Great Resignation: Create a plan to hire and retain staff

Many medical practices nationwide continue to face staffing shortages. If your practice is one of them, you need a plan to recruit and retain top talent. This article provides several suggestions, one of which is to offer remote positions. For example, billers, coders, and schedulers may be able to work remotely at least part-time. Equally as important are competitive salaries, comprehensive benefits, and long-term growth opportunities.


Electronic prior authorizations: ONC is seeking comments regarding implementation specifications and certification criteria

An overwhelming majority of medical practices struggle with prior authorizations. The good news is that the Office of the National Coordinator (ONC) is trying to ease that burden. In February 2020, ONC published a report that identifies specific challenges and recommendations. Now it’s seeking public comments on electronic prior authorization standards, implementation specifications and certification criteria that could be adopted within the ONC Health IT Certification Program. Note that comments are due March 25, 2022.


About us

Physician Practice Resources, Inc., founded in 2002 and headquartered in Midlothian, IL, is a full-service company that partners with small and large healthcare organizations to build solutions that enhance operational effectiveness, improve clinical documentation, and decrease overall compliance related risks. Contact us at https://www.ppr-corp.com/about-ppr-corp/ for more information.


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