Introduction In the world of healthcare, pediatric practices play a crucial role in nurturing the health and well-being of our youngest population. While many pediatricians choose to join larger healthcare systems or hospital networks, there’s a dedicated group who opt for independence. Operating an independent pediatric practice comes with a unique set of challenges and…
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…
Overview: Pediatric phone triage protocols are structured interviews that help a nurse or other medical provider make a decision about whether a patient needs to be seen immediately. This decision is referred to as telephone triage, and it’s an important part of the patient phone call process. There are several approaches to pediatric phone triage…
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…
Every year, the practice leaders/owner(s) should evaluate the overall value proposition of their pediatric practice. Evaluating the value proposition of a medical business can range from a long, deep study to a summary review. A pediatric practice is a medical business and, like any business, there is a value proposition. A value proposition that is…
With October essentially being the first full month in fall, many of us are enjoying changes in the leaves or are thinking about the excitement of Halloween and other fall events to come. With that being said, October is also a good time to plan for the upcoming winter season. Starting in October, instances of…
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