Payment Advocacy and Medicare Quality Reporting Assistance
Helping physicians with payer issues and concerns.
HCMS has been providing payment assistance and working to resolve payer-related issues for many years. Since the inception of the Payment Advocacy Program in 2000, HCMS has collected more than $26,800,000 in improperly paid claims, free of charge, for our physician members.
Medicare Quality Reporting Program Assistance
In addition to claims disputes, the Payment Advocacy Program assists physicians with many other issues and concerns. We work closely with our contacts at a multitude of agencies to assist physicians, including Houston market payers, the Texas Medical Association, the Texas Department of Insurance, Texas Health and Human Services Commission, CMS, etc. Below is a small sample of the types of cases handled by this program:
- Claims disputes - HCMS successfully obtained claims payment in the amount of $957,000 for one practice for hundreds of improperly processed claims by a large Houston market payer.
- Audits - HCMS has assisted several practices with payer audits. In one instance, a practice was saved over $51,000 in recoupments.
- Improper refunds/recoupments - Many physicians experience recoupments. We aided one practice in retrieving over $73,000 in improperly recouped claims payments.
- Claims denials - Much of our work revolves around improper claims denials and appeal determinations. Often appeals are denied despite evidence that the claim was payable. In one case, nearly $62,000 had been denied erroneously and appeals were unsuccessful. HCMS was able to obtain payment for these claims from a large Houston market payer.
- Contracting/credentialing - HCMS has intervened on several cases where contracts or providers were loaded improperly, resulting in out-of-network denials. With our assistance, $43,000 was owed and paid to a practice for several months of denied claims. We also recovered $175,000 in denied claims due to enrollment issues for another large practice.
- Preauthorization - HCMS assists with preauthorization claims denials, problems with obtaining preauthorizations, and other issues related to preauthorization.
- Regulatory violations - HCMS is particularly focused on addressing regulatory violations regarding SB418, payment and recoupment deadlines, fee schedule and contract requests, expedited credentialing, utilization review, etc. and assists in filing complaints when all other avenues have been exhausted to TDI, the CMS Regional Administrator, HHSC, ERISA, and other agencies.
The Payment Advocacy Program also answers questions and concerns regarding innumerable issues such as HIPAA, patient-physician relations, regulations and legislation, Medicare enrollment and revalidation, and most issues relating to the business of medicine.
Medicare Quality Reporting Program Assistance
In conjunction with the Payment Advocacy Program, HCMS offers a range of free support to help our members who actively participate in the CMS Quality Payment Program (QPP), specifically the Merit-based Incentive Payment System (MIPS)
. Each year CMS assesses a pre-set penalty percentage (starting in 2019) to physician’s Medicare Fee Schedule payments for non-participation in the MIPS program. It is our goal to work with practices to help them avoid these annual penalties and ideally achieve participation bonuses to help boost payment rates. Below are some of the ways we assist practices with this goal:
- MIPS Education - HCMS provides a plethora of education through their online resources, through email and over the phone (or in person when necessary). Contact us at 713-524-4267 or email@example.com.
- Eligibility Determination - HCMS can help practices identify if they will be required to participate in MIPS based upon their eligibility information provided by CMS. Depending upon their Medicare Part B income and beneficiaries, many small practices may be exempt from participating.
- Readiness Assessment - HCMS works with practices to build a better understanding of how ready they are to participate in MIPS based upon participation in previous Medicare reporting programs (i.e. PQRS and Meaningful Use). This assessment will provide a foundation of information on how much MIPS education is needed as well as what level of participation a practice is ready to take. For example, some practices may need to focus their efforts on doing enough to avoid the penalty while others may be well equipped to participate at a higher level and attempt to maximize their MIPS bonus payment.
- Selection of Measures/Activities - HCMS works one on one with practices to help identify measures that are appropriate for their specialty and reporting capabilities. Additionally, for those practices that have processes in place from retired reporting programs such as PQRS and Meaningful Use, HCMS will analyze previous measures and create resources to help transition the processes in place to minimize administrative burden while ensuring that no data is missing or incorrect.
- Step-by-step Guides - HCMS annually develops MIPS Step-by-Step Guides for each category. These guides are tailored to each year’s reporting requirements and provide easy to follow instructions with images to help practices begin the MIPS reporting process on their own.
- Feedback Review - After practices have reported their MIPS data to CMS, HCMS will help analyze their feedback performance results and if necessary identify areas that can be improved upon to increase score potentials in future reporting years.