Running a pediatric practice is a team effort. At the heart of the operation is a partnership between the Physician Owner and the Practice Administrator — the duo responsible for both the clinical mission and the business engine. Note that in a small practice the Physician Owner might function as both the Practice Administrator and…
In a pediatric practice, the Revenue Cycle Management (RCM) process is more than just billing—it’s a collaborative system that starts the moment a patient schedules an appointment and ends when the payment is received. Every team member plays a critical role, and understanding these roles is essential to improving cash flow, reducing denials, and enhancing…
Since the COVID19 Pandemic started in 2020, the approach by payers related to telehealth has been fairly consistent and the CPT coding is the same CPT codes used for in person visits (e.g. 99212-99215). This is changing with 2025 since the Center for Medicare and Medicaid Services (CMS) provided an entirely new CPT coding approach.…
In 2024, there is a new code that has had much discussion related to ‘appropriate use’. This discussion included a number of publications from the American Academy of Pediatrics. Based on the guidelines and discussions, below is the basic information related to this new 2024 code. What is this code for? This code was…
In early 2024, many healthcare providers, including pediatric practices, were significantly impacted by an unexpected outage at Change Healthcare, a leading healthcare technology company. This disruption, spanning from late February to early March, affected various services and caused widespread concern among medical professionals who rely on Change Healthcare’s systems for their daily operations. Here’s a…
Background The RSV prevention, Beyfortus (nirsevimab) which is a monoclonal antibody, was approved by the FDA on July 17, 2023. The CDC and ACIP provided recommendations which were published in the MMWR on August 25, 2023. The FDA accelerated approval of Beyfortus since the RSV prevention was categorized as “Breakthrough Therapy Designation”. Note that Beyfortus…
Over coding by pediatricians refers to a situation where the services provided to patients are coded or billed at a higher level than warranted based on the documentation and medical necessity. This can have several impacts on the pediatric practice: Compliance risks: Over coding or over billing can lead to compliance issues and potential legal…
Under coding or under billing by pediatricians refers to a situation where the services provided to patients are not accurately coded or billed at the appropriate level, resulting in lower reimbursement than deserved. This can have several impacts on the pediatric practice: Financial implications: Under coding or under billing can lead to decreased revenue for…
Overview: Managed care payers in the United States negotiate contracts with healthcare providers, such as pediatric practices, to set payment rates for services rendered to their members. These payment rates may be based on a fee schedule or a negotiated rate. One way that managed care payers may control costs is by “down coding” claims…
A managed Medicaid plan is a type of health insurance plan that is designed for individuals who are enrolled in the Medicaid program. These plans are managed by private insurance companies, known as Managed Care Organizations (MCOs), that have contracts with state Medicaid agencies to provide health coverage and other services to eligible individuals. Managed…
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