Medical Business Advisory

Updated on 6/28/24

What is credentialing? 

In a healthcare setting, physician credentialing is the formal process of verifying the professional records that qualify a doctor to practice medicine. The physician credentialing process includes researching their board certifications, hospital admitting privileges, education, malpractice insurance, professional references, work history, and more.

Payor credentialing is a vital safeguard for patient safety because organizations must obtain verification of the practitioner’s education, training, certificates, and licensure and maintain a file on each provider.

Why should you start the credentialing process right away?

The payor enrollment process is often the longest, most time consuming step. Giving yourself at least 90 days in advance, or even more, will give you and your credentialing team enough time to fill out and submit payor applications to avoid any delays in treating patients. By completing the longest step in the physician credentialing process first, it will allow you to begin collecting and completing the remaining credentialing to-do’s. 

Give yourself enough time in order to avoid extra stress or confusion—you should start at least 90 days in advance; you may even start even earlier, at 120, 150 or 180 days ahead of time. If a healthcare practice falls behind in credentialing, reimbursements can be delayed or denied. 

What documents do I need for the physician credentialing process?

Give your new hire a set deadline to provide the following documents:

• A fully updated CV/resume 
• Active state medical licenses
• DEA registration
• Medical school diplomas
• ECFMG certificate
• Residency, internship, and fellowship certificates
• National Provider Identifier (NPI) documentation
• Board certification(s)
• Malpractice liability insurance certification

Red flags to watch out for

Credentialing often reveals many things about a healthcare professional’s past. You should reevaluate if you encounter any of the following during the physician credentialing process, according to the National Institute of Health: 

• The reluctance of the applicant to provide permission to contact the previous employer or healthcare institution
• The reluctance of the application to provide specific references or perhaps the references are too vague
• Sudden relinquishment of licensure or medical staff membership
• Sudden loss of privileges in a hospital
• Marked gaps in clinical practice
• Short tenure at multiple hospitals
• An unusually high number of professional liability actions with the final judgment against the practitioner
• History reveals substance abuse, domestic violence, or unprofessional conduct
• History of being investigated by the state board of licensure or other healthcare organizations
• Major gaps in insurance coverage
• Evidence of poor program evaluations more than once

How The MBa Group Can Help

The Healthcare Consulting Team at Medical Business Advisors, a division of The MBa Group, specializes in working with physician’s practices, hospital departments, and other healthcare entities in Maryland, Virginia, and DC.

Our consultants possess a wealth of knowledge best suited to provide practice advisory solutions tailored to improve your operational and financial performance, including speeding up the credentialing process. Contact us to get started today! 

As explained on the official government health care site, the law has three goals:

• Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
• Expand the Medicaid program to cover all adults with income below 138% of the FPL. (Not all states have expanded their Medicaid programs.)
• Support innovative medical-care delivery methods designed to lower the costs of health care generally.

The law affects both individuals and companies. For example, according to Healthcare.gov, the law:

• Requires insurance plans to cover people with preexisting health conditions, including pregnancy, without charging more.
• Provides free preventive care.
• Gives young adults more coverage options.
• Ends lifetime and yearly dollar limits on coverage of essential health benefits.
• Helps you understand the coverage you’re getting.
• Holds insurance companies accountable for rate increases.
• Makes it illegal for health insurance companies to cancel your health insurance just because you get sick.
• Protects your choice of doctors.
• Protects you from employer retaliation.

Business rules and benefits

As noted on the IRS site, small companies — typically those with fewer than 50 employees — can purchase insurance through the Small Business Health Options Program.

Such companies:

• Must withhold and report an additional 0.9% on employee wages or compensation that exceeds $200,000.
• May be required to report the value of the health insurance coverage they provided to each employee on his or her Form W-2.
• Must file an annual return reporting certain information for each employee they cover if they provide self-insured health coverage to their employees.

Companies may be eligible for the Small Business Health Care Tax Credit if they cover at least 50% of their full-time employees’ premium costs and have fewer than 25 full-time equivalent employees.

Larger employees, based on their size, may also be able to purchase insurance through SHOP. And they must either offer affordable minimum essential coverage that provides minimum value to their full-time employees (and offer coverage to the full-time employees’ dependents) or potentially owe an employer shared responsibility payment.

The latest updates

In mid-2022, the IRS announced annual adjustments to the ACA. According to the Society for Human Resource Management, the “2023 health plan affordability threshold—used to determine if an employer’s lowest-premium health plan meets the Affordable Care Act’s (ACA’s) affordability requirement—will be 9.12 percent of an employee’s ‘household income,’ down from the 2022 limit of 9.61 percent.”

As explained in the ACA Times, this means that “employers extending health plans to their ACA full-time workforce beginning January 1, 2023, must ensure the contribution amount is no more than 9.12% of their household income.”

How The MBa Group can help

This is just an introduction to a complex series of provisions. Whether you have questions about yourself or a company you manage, work with qualified tax and legal experts to make sure you are following the ACA’s provisions — and getting everything you’re entitled to. Click here to contact a The Medical Business Advisory Group representative if you have any questions regarding this information.

The Centers for Medicare and Medicaid Services (CMS) released its proposed rule for the 2021 Medicare Physician Fee Schedule (PFS) in August of 2021. While we are still waiting with bated breath for the release of the final rule, which will hopefully be released the first week of December, it is anticipated there will be significant changes to the 2021 fee schedule that providers, and administrators alike, should anticipate and prepare new RVU values for 2021.

Significant Changes to the RVU Values for 2021

The proposed rule introduced significant changes to the RVU values in some cases, but especially for Evaluation and Management (E/M) codes.  It appears that CMS will increase the reimbursement for the core set of E/M codes; however, due to budget neutrality where there is an increase, there is a necessary cut.  Although many of the updates focus on increasing wRVU values for certain services, there is a mandatory offset in the overall per-unit reimbursement rate (Conversion Factor) for CMS payments. This amount has generally been flat or slightly increased over the last 10 years, usually ranging from $34-$36. The proposed change is expected to decrease the Conversion factor from $36.09 in CY 2020 to $32.26 for CY 2021. For more clarification to the new RVU values, contact our medical account firm for details.

New RVU Value Considerations

Things to consider while we wait for the release of the final PFS:

1. The increase in wRVU values might have a positive effect for groups that have a high volume of E/M codes, especially for primary care groups including pediatrics. For all other groups (i.e. Specialists whose volume is mostly procedural-based, opposed to visit-based) may see their Medicare payments slashed by 6-9% in some cases due to the reduction associated with the Conversion Factor.
2. It is imperative that all practices prepare an analysis of their top CPT code utilization once the fee schedule is published to see how the changes will affect your total revenue. Remember that many of the local managed care plan contracts are based on CMS rates.  For end of year planning, forecasting, and budgeting you need to know how these changes will affect your practice‘s revenue.
3. Groups that compensate physicians based on RVU values should take into account that although CMS’s wRVU value will change in 2021, the overall reimbursement may decrease. The effect of these changes should be analyzed to predict any major changes to provider total compensation. In addition, the annual statistics that many practices use to compare and contrast will no longer be valid going forward if they are not adjusted.
4. Providers who work for a health system are usually compensated based on wRVU’s and should run an individual analysis to see how the changes might possibly affect your compensation.
5. It is a possibility that due to the new RVU values and collection practices, independent groups will need to analyze and revamp provider agreements prior to the beginning of the year as well.
6. Please note the following link for the ACP which shows primary care and primary care subspecialty estimates for the overall effect of the 1/1/21 changes. For all other specialties please check with your local society.
7. And last, but certainly not least, CMS’ changes to the requirements for documentation of E/M services will also take effect January 1st, 2021. Providers and groups that are not fully educated about these changes, can easily fall out of compliance due to the new requirements surrounding areas such as time-based encounters, medical decision making, etc. 

Major changes are on the horizon to the new RVU values beginning January 1, 2021 just to add a little bit more stress to an already tumultuous year for the healthcare community.  We are monitoring this closely and will send out our analysis as soon as we have the information.  We will continue to keep you apprised of further developments as we find out.

A sigh of relief can be heard amongst the medical community last week.  Lawmakers granted an extension for providers who had their Medicare payments advanced during the early stages of the COVID-19 public health emergency.

The bill gives part B providers 1 year (originally 120 days) before CMS begins to recoup payments made under the Accelerated and Advance Payment Program.  The repayments will be made via claim reimbursement offsets.  It also states that CMS will only offset a provider’s payments after the initial grace period by 25% of the payment amount on the EOMB for the first 11 months of repayment, and then 50% of the payment amount on the EOMB for the remaining 6 months for a total extension and repayment period of 29 months.

CMS will withhold Medicare payments after the 12-month grace period for a total of 17 months before requiring providers to repay the remaining balance in full. Additionally, the law reduced the interest rates on any outstanding balances from 10.25% to 4.0%.

Backround

The Centers for Medicare and Medicaid’s (CMS) Accelerated Medicare Payment program provided advance payments to a significant number of hospitals and providers to minimize the affect of revenue shortfalls brought on by the COVID-19 pandemic. Shortly after announcing the “Medicare Accelerated and Advance Payment Program”, CMS stopped accepting applications from Part B providers on April 26^th due to the availability of funds provided by the Provider Relief Distributions enacted by the CARES Act.

Ultimately, over $100 Billion of Advance payments were distributed to hospitals and providers. Payments made under this program are an advance on future claims of the traditional fee-for-service Medicare reimbursement. Originally, repayment was due to start in August of this year via claim reimbursement offsets/withholds. Seven Medicare Administrative Centers (MACs) across the country were tasked with administering accelerated and advance payments and taking initial actions to recoup Medicare funds at some point.

Why has it Been Paused for DC and Maryland Providers?

In general, CMS instructs MACs on how to adhere to the agency’s guidance and regulatory requirements. Legislation being reviewed in Congress has caused some MAC’s to pause the recoupment process. According to an article published by the National Law Review on August 5^th, 2020 (found here) it is likely that the recoupment period will be extended given the state of COVID-19 recovery.

Figure 1 shows the proposed extended changes within the Health Economic Recovery Omnibus Emergency Solutions (HEROES) and the Health Economic Assistance, Liability Protection and Schools (HEALS) Acts for Hospitals, Providers, and Suppliers.

Figure 1 – Proposed Recoupment and Repayment Extensions

In May 2020, the US House of Representatives passed the Health Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which would extend the timeline for recoupment and repayment of the loans. On July 27, 2020, Senate Republicans introduced the Health Economic Assistance, Liability Protection and Schools (HEALS) Act, which also would extend the repayment and recoupment terms, although for a shorter period. HEROES would take additional steps of reducing the interest rate and reducing the amount of recoupment. HEALS does not include parallel proposals affecting interest rates or recoupment amounts.

What Should I do?

We spoke with Novitas Solutions, the MAC for Providers in DC, DE, MD, NJ & PA, who have decided to delay the recoupment process until they have received further guidance from CMS. By allowing a brief grace period that accounts for the activity on Capitol Hill, Novitas hopes to gain greater clarity on behalf of their beneficiaries and in turn a smoother recoupment process.

If you are a provider in Novitas’ J/L Jurisdiction (DC, DE, MD, NJ or PA) and have additional questions, contact Novitas Solutions at 855-247-8428. Press option 2 to select jurisdiction J/L, then select option 2 and stay on the line to speak to a representative about accelerated or advance payments.

How Can The MBa Group Help? 

We are monitoring this matter very closely. As always, if you have any immediate questions about how these new provisions will impact your practice, please contact us today!

Early this month, the American Medical Association (AMA) published an update to the Current Procedural Terminology (CPT­­­) code set.  The update includes the additional code “99072” as a response to measures adopted by medical practices and health care organizations to help prevent the spread of COVID-19, while continuing to provide high quality, in-person care to patients safely. The description for code 99072 is as follows: “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease.  Use 99072 only when safety measures are over and above those usually included during an office visit or service.”

Although initiated and approved by the AMA, the Centers for Medicare and Medicaid Services (CMS) has yet to add the code to its fee schedule. We believe it is doubtful that this code will be covered by Federal, State or Commercial payors unless the PHE is extended into 2021.  Until Medicare, Medicaid and Commercial Payers have made an official decision regarding covering code 99072 (if at all), we are advising practices interested in trying to bill for this CPT code, to consider running a test with each insurance company before implementing the code across all payors. In addition, the test will allow you to make sure all of your claims for each payor are not denied for an unrecognized CPT code on a claim. Closely monitor this code for insurance denials and make a decision as to how you will handle those denials when billing patients.  For pricing, we suggest you calculate your costs for this extra work and price 99072 accordingly.