Read Mark's NHXS blog and stay up-to-date on the latest industry issues and trends.
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| | No such thing as a multiple of RBRVS
Mark Reiger
Download the Full Article as a PDF: Chances are good that one of your health plan contracts uses fee schedule language that refers to a multiple of a resource-based relative value scale (RBRVS). While it’s likely that the parties understood this multiple of the RBRVS to mean a multiple of the payment method used by Medicare, there is no such thing as an “RBRVS fee schedule” in the Medicare program. More >> | 2008 National Health Insurer Report Card
America Medical Association
The purpose of the AMA's National Health Insurer Report Card (NHIRC) is to provide physicians and the general public a reliable and defensible source of critical metrics concerning the timeliness, transparency and accuracy of claims processing by the health insurance companies that are responsible for paying these claims. Billions of dollars in administrative waste would be eliminated each year if third party-payers sent a timely, accurate and specific response to each physician claim. More >> | Claim Repricing Systems versus Practice Management Systems
By Mark W Rieger, CEO, NHXS Inc.
Physician practice management systems (“PMS”) are designed principally as robust accounts receivable products. More recently, integrated electronic medical records, eligibility and claim ‘scrubber’ functions have been ‘bolted on’ to the AR function to improve the physician’s business operations. More >> | The Economics of Audit and Appeal for Physician Practices
By Mark W Rieger, CEO, NHXS Inc.
Until recently, the economics of revenue recovery for most physician groups has not been favorable. High volume, low dollar transactions with small variances are difficult to systematically identify, aggregate, and dispute in a manner that justifies the cost. The good news is that a confluence of factors in the market has created a ‘tipping point’ towards more effective audit and appeal. More >> | Improving Payor First Time Payment Accuracy
By Mark W Rieger, CEO, NHXS Inc
Ultimately, the goal of a physician’s dispute resolution process should be to improve the first time payment accuracy rate of the health plan. Higher payment accuracy rates lower the cost of doing business with that plan. This requires that the physician identify as many variances as possible and provide feedback to the plan in an organized, timely, and efficient manner. More >> | Pricing and Clinical Edit Rules
By Mark W Rieger, CEO, NHXS Inc.
The table below shows an analysis of a major US health plan’s re-pricing rules. Re-pricing is a combination of fee schedule adjustments and clinical edits that reduces the billed charges to the fee maximum described in the fee schedule or to ‘zero’ in the case of a clinical edit. The purpose of a clinical edit is to set the allowed amount to zero. More >> | What private payers do to your claim
By American Medical Association
Download the Study as a PDF: An analysis to determine the effect of payer claim edits on electronic claims submitted by physicians was completed by National Health Exchange Services (NHXS). This claim edit study, which was requested by the American Medical Association (AMA), involved an analysis of one major commercial payer’s administrative system, including electronic claims processing, auto adjudication and payment methodologies. More >> |
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