Chasing Payments

Insurance anti-assignment clauses

By Franklin J. Rooks Jr, PT, MBA, Esq

April 2014

Many physicians have come to the conclusion that some insurance contracts are not worth having. More and more physician specialties have opted out of participating provider contracts or have chosen not to participate in the first place. Reimbursement amount is the primary reason for not participating. The amount allowed for various CPT codes simply is not enough. On top of that, there is Multiple Procedure Payment Reduction (MPPR). This ominous concept was crafted by the Centers for Medicare & Medicaid Services (CMS). The MPPR functions to reduce the allowable amount of multiple medical procedures performed during the same session by the same provider.¹ Insurance carriers, such as United Healthcare, have modeled their reimbursement on this CMS policy and implemented their own versions of the MPPR.² Often, in-network reimbursement is not commensurate with the education, skill, and value that the physician delivers.

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A Medley of Compliance Questions

By Mary R. Daulong, PT, CHC, CHP

March 2014

A:  Yes, in fact, Section 6401 of Accountable Care Act (ACA) (“Provider Screening and Other Enrollment Requirements under Medicare, Medicaid, and CHIP”) now requires that providers implement compliance programs as a condition of enrollment in Medicare, Medicaid, and CHIP. The ACA has instructed the Secretary of Health & Human Services, in consultation with the Office of the Inspector General (OIG), to develop ‘core elements’ for the mandatory compliance programs. As of today, those ‘core elements’ have not been published, but a good starting place would be to utilize the OIG’s Compliance Guidances for Individual & Small Physician Practices at: http://oig.hhs.gov/compliance/compliance-guidance/index.asp as well as the Small Entity’s Compliance Guide at this link: http://www.cms.gov/Regulations-and-Guidance/Guidance/SmallEntity/index.html?redirect=/SmallEntity/. Keep in mind, your compliance program should include all local, state, and federal regulations that govern you as a health care practitioner and a business owner.

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