Failure to Collect Upfront Payments May Put Your Practice at Risk

Is Revenue Walking Out Your Door?

Does your front desk sometimes need to be encouraged to collect copays, deductibles, and overdue balances at the time of service? If the answer is yes, you may want to share these facts:

  • Patient reimbursement comprises 30% of total revenue, putting it on par with a large commercial payer in many organizations.
  • Fewer than 40% of Americans can pay a surprise $1,000 bill with savings.
  • The average single deductible for an employee insurance plan is $1,644.
  • 18% of workers in single plans have an out-of-pocket maximum of at least $6,000.
  • It is four times more costly to pursue debt collections than receive payment from a payer.
  • The chance of collecting payment drops an average of 62% after a patient leaves the office.

Collecting patient payments before appointments has evolved over the last decade, due to the shift in financial responsibility from payer to patient. Without a comprehensive strategy to collect amounts owed by patients, practices may be putting their future in peril.

Times have changed

Sometimes providers and staff express reluctance to collect money prior to service because it’s not the way they’ve worked in the past.

Before the shift from volume to value, most reimbursement was from insurance. Providers could be confident they would get paid. In the past, some providers even waived collecting copays and deductibles because the amounts were relatively small, and thresholds didn’t take long to meet. The rise in higher copays, deductibles, and coinsurance has changed that.

Not only does it take more time for patients to meet their deductibles, but payers are also more sensitive to the contractual obligation of patient payments. Waiving copays, coinsurance, and deductibles are considered kickbacks to the patient, and providers risk losing their contracts if caught. If a government payer such as Medicare discovers patients are not paying their share, providers risk fraud charges.

Another reason some providers use for not collecting before service is they think it is somehow illegal to do so, which is not the case. The Emergency Medical Treatment and Labor Act (EMTALA) stipulates that an emergency department cannot withhold service because of an inability to pay. Private practices, on the other hand, are in different circumstances. Unless an insurance contract specifically states otherwise, healthcare organizations can collect payment before services are rendered.

Best practice is collecting payments before service

Professional healthcare organizations, such as the MGMA, HFMA, and AHIMA, advocate collecting payment before service whenever possible. In addition to collecting copays and deductibles before the visit, best practice recommendations include:

  • Always verify insurance before the visit. Some practices verify when an appointment is made, three days before the appointment, and on the day of the appointment to confirm nothing has changed.
  • For large amounts, consider accepting a partial payment at the time of service.
  • Credit-card-on-file may be a good option for specialty practices that see patients on a regular schedule (such as allergy or psychotherapy).

Your front desk is the best place to set payment expectations

The top reason why payments are not made at the time of service is that the front desk didn’t ask. It is critical that staff understands why payment is necessary and have training around how to ask for payments. In addition, many organizations have financial counselors or members of staff authorized to have deeper conversations with patients to help them understand their payment options.

Your patients expect convenient payment options

The patient consumer mindset is well documented. Increasingly, patients expect to know how much a visit will cost and are sensitive to price. Another aspect of consumerism is the expectation that payment will be easy and feel like any other bill. Organizations that offer convenient payments options via a website, mobile phone app, or text position themselves to collect more revenue in less time than waiting for a check in the mail.

The consumer mindset also makes the conversation about cost a bit easier. People are accustomed to paying for goods and services upfront and payment at the time of service is the norm in most industries. In normal circumstances, why should it be any different in healthcare?

Collecting payments can be challenging – using the right partner for practice management software and billing makes it easy. Contact us today at (412) 424-2260 or visit to learn how we can help you optimize workflows, streamline claims, and maximize revenue.

Are E-Prescriptions Putting Your Practice at Risk?

Non-compliant practices can result in criminal charges, fines.

On January 1, 2021, the Support Act made mandatory the use of electronic subscribing for all controlled substances (EPCS) covered under Medicare Part D. However, compliance will not be enforced until January 1, 2022, to give health care organizations adequate time to adjust workflows to meet the new standards.

The goal of the Act is to clamp down on illegal prescribing of schedule II-IV drugs. To that end, three components will be required to confirm the prescriber identity:

  • Identity proofing – to confirm the identity of the prescriber
  • Digital signature – to authenticate the prescription
  • Two-factor identification – in addition to identity proofing, practices will need to adapt either biometrics or tokens to verify the prescriber

The DEA mandates that providers cannot delegate their signatory approval under any circumstance and are responsible for ensuring all prescription elements are valid, including drug name, strength, and quantity. The DEA also compels staff members to maintain custody of their hard token. “…The practitioner must retain sole possession of the hard token… and must not share the password or other knowledge factor with any other (staff member). The practitioner must not allow any other person to use the token or enter the knowledge factor or other identification means to sign prescriptions for controlled substances.”

According to the National Federal Defense Lawyer Group, prescription drug fraud is usually considered a 3rd or 4th-degree felony. Persons convicted of third-degree felonies can be punished for up to five years in prison, while 4th-degree felons can receive up to 18 months. A recent case in Williamsville, NY, illustrates the importance of safeguarding tokens to protect against e-prescribing fraud. A doctor was fined $60,000 when her employee used her token and password to write over 150 illegal prescriptions for controlled substances.

Although it is critical to be aware of federal regulations, compliance with state laws may be a more pressing concern for many organizations since they often place further restrictions on how prescriptions are transmitted to a pharmacy.

State laws may be more restrictive than federal

Many state laws regulate prescription preparation, validation, and transmission. For example, NY expressly prohibits employees of a provider from electronically signing a prescription, although the staff can prepare prescriptions for signature. A staff member can only transmit an electronic prescription if it is independent of the review and signature process; if a token is required for submission, the provider must submit the prescription.  NY also prohibits anyone but the practitioner from converting an electronic prescription for a controlled substance into an electronic fax. Find a guide to state laws concerning prescriptions here.

Standing orders and refills may not be exempt from regulations

According to a leading nursing education organization, “RNs cannot order medications or refills… An RN is allowed to transmit an order by an authorized healthcare provider, but… the order must be reviewed, approved, and signed (or some other form of attestation) before transmitted.”

Other crimes can be associated with prescription fraud

Non-compliant prescription practices can leave your organization vulnerable to crimes other than prescription fraud, including identity theft, forgery, health care fraud, and insurance fraud – all of which can bring hefty fines and prison sentences no matter where your office is located.

According to the CDC, opioid deaths have increased more than six times since 1999 and account for over 70% of all drug overdose deaths. Unfortunately, health care workers are in an ideal position to obtain drugs illegally. It may seem easier and quicker to delegate prescription writing and e-prescription authority to healthcare staff, but ultimately, you put your practice and reputation at risk. In the end, providers need to weigh the time-saving benefit of granting staff prescription writing authority against the penalties associated with facilitating prescription drug fraud. Many providers would agree that choosing to spend a few extra minutes attending to prescriptions is a better alternative to fines and imprisonment.

Changing health care rules and policies can be confusing – using the right partner for practice management software and billing makes it easy. Contact us today at (412) 424-2265 or visit to learn how we can help you optimize workflows, streamline claims, and maximize revenue.

Optimize Telehealth After COVID

Strategies for making telehealth compliant and profitable.

Was using telehealth a priority for your provider group before COVID? If you are like many practices, it wasn’t even on your radar. The COVID pandemic pushed telehealth to the forefront, and a service that was little more than an afterthought became a lifeline both for practices and patients. A study published by Health and Human Services (HHS) found that over forty percent of Medicare primary care visits were via telehealth in April of 2020, a massive jump from the .1% utilization before the health emergency.

Now that patients and providers have discovered the value of telehealth, it’s here to stay. Many practices are asking how to ensure compliance after emergency health initiatives are lifted and how to optimize the service best as patient volumes return to normal. Here are our top tips and strategies to maximize telehealth after the pandemic.

Cover your legal bases

Check with your malpractice provider to confirm that telehealth visits are covered under your policy after the health emergency ends. Contact your state medical association or society for information about vendors and other state-specific/specialty information. Often telemedicine is only payable if the patient is in the same state as the provider. Confirm individual payer policies about telehealth visits in general and any out-of-state restrictions.

Determine which services offer the most value in terms of time and convenience

If your office has been using telehealth services during the pandemic, you most likely already have a good idea of where they are most effective. However, there may be other services to offer. An excellent guide to finding additional services can be found in available telemedicine codes.

Analyze the profitability of telehealth

First, check payer fee schedules to find reimbursement rates. Then, determine the costs associated with utilizing telehealth. Be sure to include expenses related to any software or hardware, labor for providers and support staff, and any miscellaneous costs such as office space rental and furniture. After you have worked out roughly how much visits cost to conduct, take another look at your fee schedules to determine which visits are in your practice’s best interest. After analyzing the data, you may see that certain visits are profitable for some payers and not others. Analysis will tell you where to continue providing or expanding services, and which ones to limit.

Decide which patient populations can access telehealth

In the interest of creating a provider-patient relationship, some practices may want to consider seeing only established patients virtually after emergency measures have been lifted. There may be other patient populations that may benefit more from in-person rather than virtual visits.

Optimize your telehealth schedule

According to the HFMA, the average primary care physician sees about 12 patients per 4-hour shift. “With telehealth, physicians may be able to ‘see’ 16 or more patients in that timeframe.” Consider assigning different time values to telehealth visits. Also, consider blocking off certain times per day for low-level same-day visits or routine check-ins, or even create virtual visit shifts for providers. Switching back-and-forth from in-person to virtual visits slows down efficiency which will impact profitability.

Confirm telehealth coding and payer payment policies

Invest in telehealth training for your coders to ensure you are capturing all available revenue. Many professional organizations have issued guidelines, such as the American Academy of Pediatrics and the American Psychological Association. Be sure that documentation meets payers’ standards by reviewing their telemedicine policies.

The future of telehealth

Telehealth technology and policies will continue to evolve. As they do, an exciting subset of telehealth is Digital Health Technology (DHT). DHT devices gather health information from the patient and electronically transmit data to the provider. Strides are being made in hypertension and other disease management, and DHT has the potential to bring telehealth to a whole new level. If you are soon investing in a telehealth platform or EHR, the potential for integration of DHT may be an important criterion to consider.

Changing telehealth rules and policies can be confusing – using the right partner for electronic health, practice management and billing software makes it easy. Contact us today at (412) 424-2260 or visit to learn how we can help you optimize telehealth visits, streamline claims, and maximize revenue.

What to Know: 2021 Quality Payment Program (QPP) Final Rule and MIPS

It’s that time of year again… time to make decisions regarding the Quality Payment Program (QPP) and Merit-based Incentive Payment System (MIPS) for 2021. Payments in 2023 (based on 2021 data) are scheduled to have a potential positive/negative adjustment of ±9. With so much reimbursement at stake and so much information about categories and measures, making MIPS decisions can be overwhelming. We’ve put together a quick overview of changes for 2021 to help guide your way.

MIPS Reporting

Merit-based Value Pathways set to begin this year have been postponed until 2022 due to COVID. Therefore, providers can report data through the traditional Merit-based Incentive Payment System (MIPS) and the new APM Performance Pathway (APP). The APP is a new reporting framework that is complementary to MIPS Value Pathways (MVPs). The new APP is available to eligible clinicians, groups, or APM Entities that participate in MIPS APMs. According to the American College of Physicians, clinicians participating in APP are likely to fall into one of two scenarios: “1) their model does not meet the criteria to be considered an ‘Advanced APM;’ or 2) they fall short of Qualified Advanced APM Participant (QP) Thresholds.”

More about the APM Performance Pathway (APP)

The category score for Improvement Activities will be automatically assigned according to the MIPS Alternative Payment Model (APM) of the participating clinician. All APM participants who report through the APP will earn a 100% score.

The use of the CMS Web Interface to collect data for MIPS using the APP quality measure set will continue for 2021 but will end at the beginning of the 2022 performance period.

The APP quality measures contain:

  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS
  • 2 measures calculated by CMS using claims data
  • 3 quality measures reported at electronic clinical quality measures (eCQMS), MIPS CWMS, or Medicare Part B claims measures


Traditional MIPS Performance Thresholds and Weights for 2021

The performance threshold for 2021 will be 60 points for individual clinicians, provider groups, and APM Entities reporting traditional MIPS.

The finalized category weights:

Individual and Groups

  • Quality performance: 40% (5% decrease from 2020)
  • Cost performance: 20% (5% increase from 2020)
  • Promoting Interoperability remains at 25%
  • Improvement Activities remains at 15%

APM Entities

  • Quality performance category weight is 50%
  • Cost performance category: 0%
  • Promoting Interoperability: 30%
  • Improvement Activities: 20%

Traditional MIPS Performance categories

There are several finalized policy changes, including:

  • Significant changes to 113 quality measures
  • Removal of 11 quality measures
  • Addition of 2 new administrative claims measures
  • Revised scoring for measures with specification or coding changes

Note: CMS decided they have sufficient information to calculate historical benchmarks. They did not enact the proposal to use performance period benchmarks as the only means to score quality measures in 2021 or to use 2021 performance period benchmarks to decide if a measure is capped at seven points.


Promoting Interoperability category:

  • The Query of Prescription Drug Monitoring Program (PDMP) measure remains optional and is worth 10 bonus points
  • ‘Incorporating’ has been replaced with ‘reconciling’ for the Support Electronic Referral Loops by Receiving and Incorporating (now Reconciling) Health Information
  • A new, bi-directional exchange measure has been added as an alternative reporting option to the existing Health Information Exchange (HIE) measures.
  • Certified electronic health record technology (CEHRT) requirements are updated according to the ONC 21st Century Cures Act Final Rule


Policy changes to Cost and Improvement Activities Performance categories

MIPS has updated existing Cost Performance measure specifications to include telehealth services. One activity has been removed, and two other activities modified for Improvement Activities.  COVID-19 clinical data reporting continues with the modifications outlined in the September Interim Final Rule with Comment (IFC)

Helpful Information

  • Find information about available MIPS measures and categories here.
  • Registration for reporting via the CMS Web Interface for 2021 is between April 1 – June 30. Learn more about registration here.
  • Qualifying Participant Determination is available in July here.
  • October 3, 2021 is the last day to start a 90-day Performance Period for Promoting Interoperability and Improvement Activities.
  • The submission window for PY 2021 opens on January 3, 2022

Trying to keep up with MIPS categories, measures and reporting can be overwhelming – using the right partner for practice management software and billing makes it easy. Contact us today at (412) 424-2260 or visit to learn how we can help optimize MIPS, streamline claims, and maximize revenue.

2021 CPT Coding Updates

The new year has certainly brought more than its share of coding updates. Here’s a quick round-up of what to know for 2021.

2021 E/M coding updates

After many years of deliberation, 2021 E/M coding has been updated to be based on either medical decision making (MDM) or time as the main criteria for determining the level of service. The extent of history and physical examination are no longer used as elements to determine accurate coding. Still, providers are expected to rely on their professional expertise to decide the relevant information required and document it in the patient history. Outpatient E/M visits will no longer use the 1995 or 1997 guidelines.

Level 1 new patient E/M code 99201 has been eliminated, and 99211 is considered a straightforward diagnosis and treatment – to the extent that the presence of a qualified health professional may not be necessary.

The rest of the levels have been shifted to help make MDM determinations more straightforward:

Code Level of MDM
99202/99212 Straightforward with minor problems and minimal complexity and risk of morbidity
99203/99213 Low with minor problems, limited complexity, and low morbidity risk
99204-99214 Moderate with acute or chronic illness, review of data necessary for diagnosis and/or treatment, and moderate morbidity risk
99205/99215 High with more than one chronic disease with severe exacerbation or progression or acute illness or injury that poses a threat to life or bodily function, an extensive review of data necessary for diagnosis and/or treatment, and high risk of morbidity from additional diagnostic testing or treatment


When time is used as the main element for determining E/M levels, it is critical that exact timekeeping is recorded in the patient record. Time requirements for 2021 E/M coding are as follows:

Level New Patient (minutes) Established Patient (minutes)
1 N/A N/A
2 15-29 10-19
3 30-44 20-29
4 45-59 30-39
5 60-74 40-54

Codes that can be used to indicate prolonged level 5 new and established patient E/M visits, as well as codes to show increased complexity for level 5 visits, have also been added for 2021.

New COVID vaccine codes are tied to the type of vaccine

To track distribution and aid in analysis, codes have been added to indicate vaccine types and vaccine administration:

Code Descriptor Admin Codes Manufacturer
91300 mRNA-LNP, spike protein Dose 1 – 0001A

Dose 2 – 0002A

91301 mRNA-LP, spike protein Dose 1 – 0011A

Dose 2 – 0012A

91302 DNA, spike protein, Oxford 1 vector Dose 1 – 0021A

Dose 2 – 0022A

91303 DNA, spike protein, adenovirus vector Single dose – 0031A Janssen

New COVID vaccine codes will be added as vaccines are approved for use. Check the AMA website for information.

Also note:

CPT 99072: additional supplies and staff time to mitigate transmission of respiratory infection disease

There are many more changes included in the 2021 CPT code set

According to the AMA, there were 329 changes to 2021 CPT coding – including 206 new codes, 54 deleted codes, and 69 revised codes. Many new codes are tied with new technology. For example, CPT 92229 was added for retinal imaging with automated point-of-care (for primary care settings). CPT range 93241-93248 was added to include continuous cardiac monitoring and detection via a patch worn by patients.

There will be more CPT coding updates in 2021

Keeping track of CPT coding changes while managing a healthcare organization impacted by the COVID pandemic may be challenging in the year ahead. In addition to regularly monitoring CMS and AMA updates, MACs and payers will be publishing their guidance about coding and proving medical necessity. Staying on top of the latest changes will be critical to your practice’s financial health – using the right partner for practice management software and billing makes it easy. Contact Virtual Revenue Solutions today at (412) 424-2260 or visit to learn how we can help keep you informed of coding changes, optimize MIPS, streamline claims, and maximize revenue.

Population Health During COVID: Moving Together in the Right Direction

We’ve all been hearing the term population health alongside news of the pandemic so what exactly is population health, and how does it differ from public health? 

First, a bit of history. The awareness of the term “population health” increased with the rise of the “Triple Aim” of healthcare, coined by the Institute for Healthcare Improvement in 2007. The Triple Aim is defined as, “Improving the patient experience of care (including quality and satisfaction); improving the health of populations and reducing the per capita cost of health care.”

Although the Triple Aim sharpened the focus on ‘health of populations,’ frequently referred to as population health, it didn’t give an exact definition of which population, which has become problematic. Over time, it has morphed into the terms population health management or population medicine. Although many envision a geographic location as the foundation of a population, that isn’t necessarily the case. Clinical settings often use the term to describe patient groups, such as cancer patients. Although there is a discussion in the highest levels of health policy about semantics, when the term population health is used, it may be a good idea to clarify if it is a geographical or patient subgroup reference.

Public health is different than population health

According to the Centers for Disease Control and Prevention (CDC), “public health works to protect and improve the health of communities through policy recommendations, health education and outreach, and research for disease detection and injury prevention.” Therefore, the main difference between population and public health is that public health relies on official policies to drive change. In contrast, population health elicits change through all stakeholders, including providers, patients, payers, academics, and the communities themselves.

Population health makes suggestions for allocation of resources

The CDC’s 6|18 Initiative is a prime example of a population health program. Through its Medicare and Medicaid branches, it’s reaching out to partners to work together and improve beneficiaries’ health while lowering costs. It focuses on six areas of health improvement:

  • Reduce tobacco use
  • Control high blood pressure
  • Improve antibiotic use
  • Control asthma
  • Prevent unintended pregnancy
  • Prevent Type2 Diabetes

Each area of focus contains recommendations to improve patient outcomes and reduce costs. For example, to control high blood pressure, the CDC urges stakeholders to improve medication compliance with strategies such as ensuring low copayments, easy-to-read packaging, care coordination between providers, and encouraging self-monitoring with home blood pressure monitors.

Population health during COVID

There is no doubt that the pandemic will significantly affect population health initiatives. The Institute for Healthcare Improvement suggests that organizations focus on a framework of four concepts during COVID:

  1. Physical and/or Mental Health – Identify those in the population at increased risk during COVID and ensure access to appropriate care.
  2. Social and or Spiritual Well-Being – Consistently screen for social and spiritual well-being and utilize partnerships in community-based organizations to help meet patient needs.
  3. Community Health and Well-Being – Share data and work with other organizations to address caregiving strengths and weaknesses.
  4. Community of Solutions – look outside traditional roles when seeking solutions; for example, consider a community-based business to manufacture PPE rather than a conventional supplier.

When viewed through a population health lens, we can see there have been many COVID-related population health strategies already put into place. Increased access to telehealth, programs to support front-line healthcare workers, car parades for graduations, and using alternative sites for testing are examples of population health in action.

What you can contribute to population health

As a healthcare provider, participation in a population health initiative can be good business. It’s an opportunity to strengthen professional relationships as well as introduce your practice to the community. Contact your local health authority, hospital system, or community outreach center to learn more about population health initiatives in your area.

Staying on top of the latest regulations and initiatives can be challenging– using the right partner for electronic health records, practice management and billing software makes it easy. Contact us today at (412) 424-2260 or visit to learn how we can help optimize MIPS, streamline claims and maximize revenue.

Will Your EHR Comply with the New Information Blocking Regulations?

The new Final Rule has implications for providers as well as patients

Interoperability could be considered the ultimate goal of healthcare technology. Clinically, it would achieve universally accessible patient records, leading to better health outcomes. Administratively, healthcare’s push away from volume to value payment models depends heavily on its potential administrative and clinical cost savings. A provision in the 21st Century Cures Act Final Rule, which will begin November 2, 2020, aims to bring down a potential barrier to interoperability that occurs at all levels, from the provider’s office to multi-million dollar EHR companies – data and information blocking. What is data and information blocking? It’s withholding patient health information, either intentionally or unintentionally, by making its access difficult.

The Department of Health and Human Services (HHS) sounded the alarm about information blocking in the Report on Health Information Blocking published in 2015. The report stated, “While many stakeholders are committed to achieving (interoperability), current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use.”

The report alleges that some stakeholders may engage in activities that impede the exchange of health information because it is in their financial interest to do so. For example, charging “fees for data exchange, portability or interfaces,” or creating platforms that “lock-in” users and effectively block electronic communications, leading to additional services and subsequent cost.

There is some debate about whether there are intentional barriers for data exchange or only “incompetence in the industry.” Nevertheless, the Final Rule mandates that providers and vendors cannot obstruct the exchange of information (data blocking) with:

  • Practices that restrict authorized access … between certified health information technologies
  • Implementing health IT in nonstandard ways … (that could) increase the complexity or burden of accessing, exchanging, or using electronic health information (EHI)
  • Restrict the access, exchange, or use of EHI with respect to exporting complete information sets or in transitioning between health IT systems
  • …Impede innovations and advancements in health information access, exchange, and use

What the Final Rule means for providers

Healthcare organizations and providers need to be aware that intentionally manipulating data exchanges that lead to waste or abuse are prohibited (for example, tests needing to be repeated because the data was inaccessible).

Another provision to be aware of is the requirement that developers create application programming interfaces (APIs) that allow “health information from such technology to be accessed, exchanged and used without special effort through the use of APIs or successor technology.” In terms of real-world use, this will drill down to three things for healthcare providers:

  1. Patients must have access to records that require no “special effort” to obtain; this means information cannot be siloed in different electronic locations. It also opens the door to third-party application developers – patient access to records through a smartphone may soon be available.
  2. All documents should be scanned into the patient record.
  3. Transferring information from one vendor system to another may soon become more straightforward, potentially creating smoother (and cheaper) billing operations.

What providers should look for in EHR partners

Although it’s vendors’ responsibility to ensure their technology aligns with the 21st Century Cures Act mandates, providers may want to confirm their software platforms are compliant. Features to look for include:

  • Compatibility with HL7 Fast Healthcare Interoperability Resources (FHIR) Release 4
  • Optimized patient portal features that allow sharing and downloading of records
  • The ability for patients to share or link their information to third parties, such as smartphone applications

Enforcement of the Rule

Although the official start date is November 2, the OIG will use its discretion to enforce the new regulations (especially considering the COVID-19 pandemic.) Now is the time to check with your EHR partner to confirm your technology will comply with the Act’s requirements, so both your practice and patients can benefit from the new interoperability rules.

Staying on top of the latest regulations can be challenging– using the right partner for electronic health records and medical billing software makes it easy. Contact us today at (412) 424-2260 or visit to learn how we can help optimize MIPS, streamline claims, and maximize revenue.

Should You Apply for a MIPS COVID-19 Exception?

In June, CMS announced that clinicians participating in the Quality Payment Program Merit-based Incentive Payment System (MIPS) for 2020 whose practice is being adversely affected by COVID-19 can apply to re-weight their performance categories through an exception.

The two exceptions available in PY 2020 are:

  • The Extreme and Uncontrollable Circumstances Exception
  • The MIPS Promoting Interoperability Performance Category Hardship Exception

The application period for both exceptions closes on December 31, 2020.

The Extreme and Uncontrollable Circumstances Exception

This exception is designed to help organizations cope with uncontrollable circumstances (such as natural disasters) and public health emergencies (such as COVID-19). To receive the exception, an organization must demonstrate circumstances that inhibit the ability to collect the necessary information for a MIPS performance category and meet at least one of the two conditions below:

• The inability to submit the performance information for a period of time
• The process of submission would affect regular operations, which in turn would impact performance on MIPS measures

The exception application process

This year, CMS began requiring an HCQIS Access Roles and Profile (HARP) account for exception submission. After signing into QPP, the exception application is located on the left navigation bar after login. (A QPP Access User Guide to register for a HARP account is located at )

You can check on the application status by signing into QPP and be notified of the application outcome by email. Approved organizations will see an eligibility profile on QPP, but it may not appear in the QPP Participation Status Tool until data submissions beginning in 2021.

Organizations that receive approval will not have to report the requested performance categories and the remaining categories will be re-weighted. Clinicians that submit information for two or more categories will receive a final score based on the data.

There are circumstances when automatic re-weighting can occur. If a provider (groups are ineligible) is located in a CMS-declared extreme and uncontrollable event zone, they will qualify for a weight adjustment and receive a neutral payment. As of June, no qualifying events were announced by CMS. To be informed when a qualifying event occurs, sign up for QPP updates.

Clinicians can earn credit for COVID-19 clinical trial participation

Physicians that participate in a range of clinical trial types and report findings to a clinical data repository or registry may be eligible to attest their participation and receive MIPS credit. According to a letter sent by CMS to physicians in April, “MIPS eligible clinicians who report this improvement activity will earn 20 points or half of the total 40 points needed to receive a maximum score in the MIPS Improvement Activities performance category.”

Proposed boost to the Complex Patient Bonus due to COVID

CMS is revising this QPP incentive in light of the additional complexity of treating patients with COVID. Clinicians and organizations may be able to earn up to 10 bonus points for 2020 (the prior maximum was five).

Expanded use of telehealth toward measures

Forty-two quality measures can be assessed using telehealth as an encounter tool, even if the entire measure cannot be completed virtually—as long as the whole measure is performed it can be included (for example, the patient receives a blood test after a telehealth encounter).

Examples of measures eligible for a telehealth encounter include:

  • Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
  • Cervical Cancer Screening
  • Breast Cancer Screening
  • Preventive Care and Screening: Influenza Immunization

Other eligible measures include:

  • Dementia: Cognitive Assessment
  • Depression Remission at Twelve Months
  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Trying to keep up with MIPS categories, measures and reporting can be overwhelming – using the right partner for practice management software and billing makes it easy. Contact Virtual OfficeWare Healthcare Solutions today at (412) 424-2260 or visit to learn how we can help optimize MIPS, streamline claims, and maximize revenue.

The Impact of Fee Schedules

The Impact of Fee Schedules

Fee schedules play a critical role in reimbursement for every physician’s practice. Many physicians, however, don’t know what, exactly, a fee schedule is, and how their own is kept up-to-date.

Oftentimes, when we speak with physician practices and ask about their fee schedules, the physician acknowledges that they have a fee schedule, but that they have no idea who created it, maintains it, or even where it originated.

So, let’s start at the beginning…

A fee schedule is a complete listing of all the fees used by an insurance carrier to pay physicians and other providers of healthcare services/products. This comprehensive listing provides a maximum reimbursement that each carrier will pay to physicians for their services.

Often, many commercial/managed care carriers will base their fee schedules off of the CMS’ Physician Fee Schedule, and so CMS is frequently referenced as the leading authority for the average reimbursement for medical services. Each insurance carrier that a physician/physician group is credentialed and participating with will have their own fee schedule that is a part of their contract with physicians for reimbursement.

Fee schedules are also used internally by physician practices for both cash billing and carrier billing for services provided. These fee schedules are created and maintained by the physician and their billing staff and are used to ensure that the physician is collecting the maximum amount of revenue allowed by the carrier for each date of service.

Why is all of this important to physicians?

Let us provide an example…

Say you see a new patient and your internal fee schedule (what you bill the insurance company) is set at $75 for a new patient office visit CPT. The insurance carrier receives and processes the claim, and reimburses you the entire $75. That’s great, right? Not always.

Total reimbursement by an insurance carrier for a billed amount often signals that the billed amount may be too low and that the provider may be losing out on the maximum allowable reimbursement for that CPT; this is an indicator that the practice needs to review their billing fee schedule and perhaps increase the charged amount on certain CPT codes.

Conversely, imagine that the same patient has returned for another visit. You’ve updated your fee schedule and are confident that you will now collect the maximum you are owed for the service. Your billed amount is now set at $150 for this service. The insurance company receives and processes this new claim; however, this time only reimburses you for $25 of the billed amount. What happened? Is your fee schedule now set too high or did the insurance company reimburse too low?

Unless you have a copy of your fee schedule with that carrier or understand what the average reimbursement for that CPT is, it will be difficult for your biller to know why the claim was reimbursed at such a low rate.

These two scenarios are good representations of what we frequently encounter when we consult with various physician practices and organizations. It is not uncommon to uncover significant lost revenue, either because the claim was billed at too low an amount, or because the biller did not have the time, information and resources (system set up) necessary to make sure each claim was being paid correctly.

It is critical that physicians and their managers recognize this crucial piece of the billing cycle, and work to make certain that it is kept up to date within their practice management system.

If you have questions or need extra help with your fee schedule and/or other areas impacting your revenue cycle, we can provide assistance.

Patient Statements: Your Secret Weapon to Improve Patient Payments

Every year, patients are paying more out of pocket for their healthcare – and given recent headlines, the situation may become worse. As a result of COVID-19 costs, one organization estimates that premiums for private plans will increase between 4 – 40% next year. In addition to monthly premiums, deductibles are on a steady rise as well. The percentage of workers with a deductible of $2,000 or more has increased from 18% to 28% over the past five years.

As a result of the shift in reimbursement from insurance payers to patients via high deductibles, patient revenue is a top source of income for many providers, following closely behind Medicare and commercial plans such as BCBS. Even before the pandemic, patient collections were a significant concern for providers, as indicated by a survey where 58% said collecting from patients was their top revenue cycle concern.1

Are organizations underestimating the impact of patient statements, and by association, patient payment options on their bottom line? Some statistics to consider:

  • 70% of consumers reported being confused by their medical bills
  • 80% said an easy-to-read statement was important for their medical bill experience
  • 65% would consider switching providers for better healthcare payments experience
  • 80% said that payment channel choices were very or somewhat important to their medical bill payment experience

Despite worries about collecting from patients, 41% of providers haven’t updated their patient statements in five years or more.1

The cost of patient statements

In addition to patient preferences driving a re-think of how you bill, statement material and labor expenses can impact your bottom line. The material costs are well over a dollar to mail a statement, and of course the labor of coordinating their generation and mailing needs to be factored in as well.  According to an MGMA Stat poll, over 46% of respondents mail three statements before a patient account is sent to collections.

Given patient perceptions, and the high cost of sending statements, taking a second look at your patient billing and payment systems may be in order.

Boost revenue with easy patient statements and payments

When updating your patient billing and payment systems, there are three critical components to bear in mind: statements, payments and past-due reminders. VOWHS can provide your practice with these features, as well as electronic statements receive payments faster.

Customized statements provide opportunities

Customized statements, especially electronic statements (e-statements), are an excellent way to decrease costs, a resourceful way to communicate with patients and useful tool to reduce billing question calls into the office. Practices that take advantage of customized messaging can communicate things such as:

  • If you think your claim is denied in error, please contact your insurance carrier to confirm coverage before calling us.
  • Question about your bill? Go to our website (insert your web address) for answers to frequently asked questions.
  • Want to speak to a billing representative? Call (insert your billing phone number). Press (X) for a callback if you don’t want to wait on hold.

Customized e-statements are also an opportunity to tell your patients what they owe in a straightforward way. Columns can be tailored into easy-to-understand language. For example, rather than calling an amount due “coinsurance,” customized statements can call it “your portion.” Rather than using the word “adjustment” at the top of a column, you can choose to call it an “insurance discount.” Small changes in wording can create a tremendous positive impact on patients. For example, a heart specialist practice was able to collect nearly $3,000 more a week with customized statements.2

The convenience of online bill pay encourages payment

It is well documented that patients are in a consumer mindset. Many see a statement as just another bill to pay and think, “If I can pay my utility bill online, why not my medical bill?” Younger patients may not even possess a checkbook! Online bill pay offers the convenience of 24/7 availability. It also makes it easy for caretakers to pay bills for their loved ones on a credit card rather than directly from a bank account. Up to 75% of patients will pay their bills online given the opportunity.2

Automated past due reminders

Most patients have every intention of paying their medical bill. However, sometimes other bills take priority, or they are distracted by life events. Rather than sending out another costly statement, automated phone calls and texts can be a quick and effective reminder that their bill is past due. If you offer online bill pay, some patients near a computer will pay as soon as they receive the alert. One practice in St. Louis used a combination of online bill pay and automated reminders to shave almost a week off their accounts receivable (A/R).2

Is it time to investigate how updating your patient billing and payment systems can improve revenue? Using the right partner for practice management software and billing makes it easy. Contact us today at (412) 424-2265 or visit our RCM page. 

1 Four ways group practices can create a better patient experience. MGMA.

2 POS Professional Office Services, Inc. (2020).