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…
As discussed on a previous blog article a few years ago, Accounts Receivable Days is a key performance indicator to monitor. Today, there was an interesting article in the Wall Street Journal that discusses the importance of monitoring the amount of Accounts Receivable in a business and that large businesses use a metric known…
In previous articles, we have provided a summary related to the selection of appropriate Evaluation and Management (E&M) codes (99202-99215) for a sick visit, or as an additional service provided during a well visit. The selection of said E&M code is a key component of pediatric office visits. While previous articles have described how to…
Revenue Cycle Management of a pediatric practice is a team effort. Influences on pediatric revenue cycle performance include the front desk team members, medical assistants, providers, and the medical billing team. Previous blog articles include articles on the importance of each of these roles, and the potential impact they pose on practice revenue. The medical…
Are documenting/submitting phone consultations and/or secure message exchanges worth the time and effort needed to appropriately do so? Many consultants may come up with ideas on how to enhance practice revenue without taking into consideration if the work required of the pediatric providers is worth the results, whereas a pediatric practice owner/administrator is more prone…
The selection of the appropriate E&M code is dependent upon time and/or complexity. This article provides an analysis on the addition of appropriate sick visit codes (e.g. 99212-99215) for when a child is present for a well visit. The determination of adding a sick visit code during a well visit is decided per the provider’s…
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