Medical Payers & Insurance Companies
articles, webinars, tips, links, forms, files and other resources related to coding, reimbursement and compliance for medical payers and insurance companies
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recent articles
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Nov 6th, 2024
Consumer Health Plan Appeals
As part of the Patient Protection and Affordable Care Act (PPACA) of 2010, expanded appeal rights for patients have been granted in all states. These regulations grant the right to both an internal appeal through the insurance plan, as well as an independent external appeal.
Nov 5th, 2024
Designation of Authorized Representative for Appeals
A Designation of Authorized Representative is a formal document (form) that allows a third party, such as a friend, family member, attorney, or healthcare provider, to act on behalf of the patient/beneficiary in handling specific aspects of an insurance claim or appeal
Oct 31st, 2024
Managed Care Organizations (HMO, PPO, etc.)
Managed care is a type of health insurance system designed to reduce healthcare costs while ensuring high quality care through coordinated, cost-effective, and efficient delivery of services. Learn the characteristics of these types of programs.
Broadly speaking, managed care is a healthcare delivery system designed to control costs, improve quality, and manage how services are provided to enrollees. It integrates healthcare providers, hospitals, and insurers to coordinate patient care in a cost-effective way. Managed care often emphasizes preventive care, streamlined service delivery, and coordinated treatment plans.
Oct 31st, 2024
What Medicaid Information is in Find-A-Code?
Oct 30th, 2024
What are the Different Medicaid Payment Systems?
The Medicaid payment system, which funds healthcare for low-income individuals and families, is complex and varies by state. It generally works through a combination of fee-for-service (FFS) and managed care models, with federal and state governments sharing costs. This article contains information to help explain some of the different ways that Medicaid pays for healthcare services.
The Medicaid Chronic Illness and Disability Payment System (CDPS) is a diagnostic-based risk adjustment model used to calculate payments for Medicaid health plans, particularly for those covering individuals with chronic illnesses and disabilities.
A conversion factor is a dollar amount that is applied to an adjusted Relative Value Unit (RVU) to arrive at a fee. Conversion factors can be based on a geographic location as well as a national level. The article contains information from the Veterans Administration about how they create their geographically-adjusted 80th percentile conversion factors.
Aug 5th, 2024
Medicare Fee Schedule Information
Aug 1st, 2024
Telehealth Policies in the Post-Pandemic Era
by Kate Choi
Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released its proposed Physician Fee Schedule for 2025 . A major component of the proposed rule is the telehealth policies, particularly given that major Medicare telehealth waivers are set to expire at the end of 2024. CMS has...
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