In October 2010 a provision of the Affordable Care Act, Section 6402(a) amended the Social Security Act by inserting several “program integrity” elements into that law. The focus of those program integrity elements is Medicare providers and suppliers. 1 These new requirements provide direct statutory support of the long standing principle that participating providers must…
A recent case of false claims caught in an internal audit — but not reported to authorities — proved costly to both a provider and his employer. The case offers a clear reminder that not every provider audit should remain an internal affair. To read the full article, which includes commentary from PCG Software’s Chief…
As we head into 2022, we asked the Healthcare IT Today community to share some predictions for the new year. One of the hottest topics out there right now it telehealth and the new digital front door. These terms have a lot of different meanings to a lot of different people, but there’s consensus that…
Patient Experience is not just a buzz phrase. It is a major driver of health IT innovation. The healthcare industry to say the least is doing a little catch up to other industries when it comes to how their customers or patients interact with their entities. Gen Z or iGen are now entering their 20s…
A $3 million settlement of False Claims Act charges stemming from inappropriate use of the modifiers 25 (Significant, separately identifiable E/M service), 59 (Distinct procedural service) and XU (Unusual non-overlapping service) is a warning to keep an eye on habitual use of these modifiers that allow extra charges during patient encounters. Andria Jacobs, RN, MS,…
A recent HHS Office of the Inspector General (OIG) audit of selected chronic care management (CCM) claims found many instances of duplicate claims by the same provider, which suggests some practices are not paying attention to their CCM billing. “It would be interesting to see if these billing errors are just a few per provider…
Federal payers relaxed HIPAA rules to allow the use of Zoom and other common video conferencing technologies during the public health emergency (PHE) and expanded the telehealth categories covered under federal plans. Many private insurers followed suit, with some even covering patient deductibles and co-pays for select services. To read the full article, visit BC…
We know that if we’re not careful our cloned notes can lead to inappropriate data in an encounter record, which in turn can lead to denials and takebacks. But can you be prosecuted for fraud because of cloned notes? To read the full article, visit Part B News.
Standards for judging coding and billing performance should go beyond simple measurement of denial rates. To achieve better assessments, you also should weed out other causes to accurately measure their effect on the bottom line. While practices may have more sophisticated instruments for measuring the performance of their billers and coders, managers are prone to…
After the public health emergency, Section 123 could pose a problem for patients who have depended on telehealth for mental health services during the pandemic, says Andria Jacobs, chief operating officer of PCG Software, a solutions provider for healthcare organizations in Las Vegas. Once the rule goes into effect, patients might not be eligible for telehealth…
Although airline pilots receive hundreds of hours of hands-on training and flight time, every aircraft is equipped with an operations manual, along with step-by-step checklists for every conceivable scenario. An airplane is a complex conglomeration of parts, and no one person can claim to know everything. Likewise, billing and coding professionals should take the same…
CMS has proposed to make telehealth a more prominent part of health care services. While this is a help for many patients, we see that one of the largest investigations by the justice department led to the arrest of 345 people including more than 100 physicians, nurses or other licensed medical personnel for telehealth and…
In September, the U.S. Department of Justice announced its largest-ever healthcare fraud and opioid enforcement action in history, which resulted in charges against 345 defendants and alleged fraud losses topping $6 billion. Those charged included more than 100 physicians, nurses or other licensed medical personnel, so there likely were many billers and coders among those indicted.…
Rightfully so, the coronavirus pandemic has shone the spotlight on front-line medical professionals who continue to risk their lives treating patients. In the background and often working from home, though, are billing professionals whose jobs increasingly provide critical revenue for medical facilities, from single physician practices to multi-hospital health systems. To read the full article,…
Claims denials can be frustrating for a physician practice to deal with, but leaving them unattended leaves a significant amount of revenue uncollected, says Andria Jacobs, RN, CPHQ, chief operating officer at PCG Software. Her company develops healthcare applications focused on cost containment, fraud and abuse detection, based in Las Vegas, Nev. To read the…
Andria Jacobs, RN, MS, CEN, CPHQ was interviewed on HealthcareNOW Radio’s The Tate Chronicles. Listen to the full interview on HealthcareNOW Radio.
Our own Andria Jacobs, RN, MS, CEN, CPHQ was featured in Health IT Answers annual predictions feature: It is day nine of our 12 Days of Christmas Posts and we rounded up these 9 ladies in health IT. The debate still continues if 2019 is the “Year of the Woman”. The fight continues for equal pay and equal…
PCG Software was named a Top 10 Medical Billing and Coding Pioneer by MD Tech Review magazine. The magazine’s editors called PCG’s iVE Coder a next generation provider tool with coding accuracy. To read the full feature article, visit MD Tech Review.
Though the dollar figures aren’t big, OIG’s report on faulty chronic care management (CCM) billing should be concerning for any practice billing those codes, especially since some of the problems have no simple answers. The report, “Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Management Services,” released Nov. 7, is based…
Hospital staff can often be less than satisfied with their facility’s EHR, leaving organizations with the challenge of how best to optimize their systems while avoiding discontent. The problem is a common one, often caused by an array of issues—poor design, unmet expectations, and shoddy implementation, among others. By understanding the underlying causes of staff…
Healthcare fraud is big business, which is why federal and state agencies are continuing their efforts to root out instances of fraud and abuse. During the 2016-17 fiscal year, the Department of Justice (DOJ) recovered more than $2.4 billion in settlements and judgments for allegedly fraudulent practices in Medicare, Medicaid and Tricare. It was the…
One of my payers is sending back a few dozen of our claims with the E/M codes downcoded from Level 4s to Level 3s. Is this common? Should we appeal? Your first step is to establish that your physicians are in the right before considering an appeal. Don’t forget to keep the old saying in…
With E/M documentation guidelines getting a makeover in 2021, losing history and exam as factors means it will be more important to properly document medical decision-making (MDM) and, if you bill on time, time spent in non-face-to-face services. “Providers have trouble documenting MDM,” says Andria Jacobs, chief operating officer of PCG Software in Las Vegas.…
PCG Software (@PCGSoftware), a provider of software solutions designed to slow the escalating costs of healthcare, announced the launch of iVECoder™, a coding and billing intelligence platform for medical practices of all sizes and specialties. Through the cloud-based software subscription, providers can now ensure even the most complex claims are clean and accurate before they are sent…
Coding and billing platform leverages payor intelligence to improve accuracy of medical claims and speed reimbursement while reducing provider risk LAS VEGAS – April 02, 2019 – PCG Software (PCG), a leading provider of software solutions designed to slow the escalating costs of healthcare, today announced the launch of iVECoder™, a coding and billing intelligence…
A recent MGMA Stat poll showed that two-thirds of medical practices say that Medicare payments for 2019 won’t cover their costs for delivering care. That’s sobering news, not only for physicians, but also for people who are on Medicare and want their doctors to continue to accept the federal insurance. Alternative payment models in Medicare come with…
The following information appeared on, Becker’s Hospital Review. Technology is an important part of patient care delivery today. Healthcare organizations and clinicians across the country depend on health IT leaders and vendors to achieve optimal outcomes and deliver a seamless patient experience. Here are 102 women who make significant contributions to health IT advancements, leading…
New this week on Interviews Now, host Shereese Maynard & guest Andria Jacobs, RN, MS, CEN, CPHQ, COO of PCG Software, discuss current issues affecting payers, providers & beneficiaries Healthcare Now Radio. HealthcareNOW Radio Podcast Network · InterviewsNOW: Current Issues Affecting Payers, Providers & Beneficiaries w/ Andria Jacobs To listen to more, visit Healthcare NOW…
Here is Health Data Management’s weekly roundup of health IT contract wins and go-lives: The Urology Group, with 15 sites serving parts of Ohio and Kentucky, and the Michigan Institute Urology, with 22 sites in southeast Michigan, both are replacing legacy electronic health record systems and selecting the same vendor—Integra Connect. Some 39 physicians at…
Integration between Virtual Examiner® and existing QuickCAP™ solutionfrom MedVision will allow for cost containment and streamlined processes LAS VEGAS – November 6, 2018 – PCG Software (PCG), a leading provider of software solutions designed to slow the escalating costs of healthcare, today announced Nivano Physicians has selected PCG’s flagship claims auditing software, Virtual Examiner®(VE), to help the California-based independent physician…
Patients who get care at a hospital often receive bills that are bigger than they were expecting. In the case of Medicare, this can happen when a beneficiary receives care at a hospital for several days but was never formally admitted to the hospital. The result is higher out-of-pocket expenses and fewer Medicare benefits—the biggest…
Andria Jacobs, RN, MS, CEN, CPHQ The emphasis on holding individuals acccountable for corporate malfeasance has received support from top Department of Justice officials since the change in administration. Companies settle with the government all the time for various alleged offenses. In nearly all instances, the company rarely admits guilt. However, in the wake of…
PCG Software Chief Operating Officer Andria Jacobs was interviewed for this feature article on coding fraud. The piece ran in the March print issue of For the Record magazine: Experts offer advice on how to spot the warning signs of coding fraud, how to avoid it in the first place, and what to do when…
Placing seniors on observation status appears to be a tactic to avoid adding to a hosptial’s readmission rate, but it hurts seniors financially. In fairness to our senior population, hospital use of “observation status” to deny Medicare patients benefits and shift costs onto them must change. That’s why I’m heartened to hear that a federal…
By Andria Jacobs – The healthcare industry has its share of bad apples. Unfortunately, the fraudulent actions of these rotten apples leaves a very bitter taste in the mouths of millions of stakeholders. The post Q&A on Recent String of Fraudulent Claims Activity Impacting Healthcare Industry appeared first on RCM Answers. To read the full article, visit Health IT…
Industry Commentary PCG Software COO Addresses Recent String of Fraudulent Claims ActivityImpacting Healthcare Industry; Provides Guidance LAS VEGAS – October 23, 2017 – The healthcare industry has its share of bad apples. Unfortunately, the fraudulent actions of these rotten apples leaves a very bitter taste in the mouths of millions of stakeholders. Just recently, we…
From Andria Jacobs, COO of PCG Software’s new piece forAmerican Journal of Managed Care featured on October 20th, 2017: At stake is whether healthcare at the individual level should be a government decision or a decision between doctor and patient. Of course, I believe those decisions should be left to the patient and the physician.…
From Andria Jacobs, COO of PCG Software’s new piece for American Journal of Managed Care featured on August 20, 2017: Why does the cost of healthcare in the United States continue to escalate? One reason is the high cost of protecting against data breaches and insurance to mitigate the risk of potential fines. Of course,…
When the guidance from CMS was released last year on billing for Provider-Based Departments, we were staggered by the complexity and the amount of research that it will take to determine the history of these departments. The PCG staff has diligently reviewed the material and we have internally developed this white paper and job aids…
You may remember last year Tenet Healthcare settling federal fraud charges related to Medicaid maternity claims at 2 hospitals. The agreement included a $513 settlement, an admission of guilt from the 2, and a non-prosecution agreement as long as the provider cooperated with ongoing investigations. But you may not have seen the latest—the January indictment…
You’re surely aware that the Quality Payment Program (QPP) is the centerpiece of MACRA, the Medicare Access and CHIP Reauthorization Act. MACRA is replacing the much-maligned Sustainable Growth Rate (SGR) process for updating the Medicare Physician Fee Schedule. So far, so good, right? The QPP calls for physcians in Medicare Part B to choose between…
A new survey from NPR-Truven Health Analytics shows that 57% of respondents have been prescribed a narcotic painkiller at some point in their history. That might not be surprising in itself, but the percentage continues to increase, up from 54% in a 2014 survey and 50% in the 2011. Two days before the survey was…
Minimum MACRA: The Merit Based Incentive Path in CMS’s Quality Payment Program PCG Software has just released a new white paper to help educate the healthcare industry on CMS’s Quality Payment Program. You can download the full white paper here.
Despite advancements in understanding over the past few decades, the stigma of suffering from an acute mental illness continues. But it’s still troubling to note that more than half of adults with a mental illness received no treatment in 2012-13.1 In addition, one in five adults said they were not able to get the treatment…
Regardless of which presidential candidate wins in the next week, changes will be coming to Obamacare. The profile of healthcare always rises this time of year as open enrollment beings on the federal exchange, but it’s increased even more during this heated election year. It’s clear that something needs to be done, as respected accountable…
Question: A new patient comes for his Welcome to Medicare visit and a medical problem. This is his first time at the office. Do we bill “new patient” for the Initial Preventive Physical Exam (IPPE) and “established patient” for the E/M? Are there any circumstances under which a patient may go from new to established in the same encounter? Answer:…
CMS wants to require all providers and suppliers involved in Medicare Advantage services — including HMOs, Program of All-inclusive Care for the Elderly (PACE) and other organizations — to be enrolled in Medicare “in an approved status,” according to the proposed 2017 Medicare physician fee schedule. CMS perhaps is motivated by recent Congressional hearings on Medicare Advantage overspending and possible fraud, and…
Tuality Health Alliance is a physician-hospital community organization (PHCO) that includes approximately 80 primary-care physicians and 200 specialists. Based in Hillsboro-Ore, Tuality represents the interests of patients, physicians and other care providers with many national and regional insurers and health plans, and is responsible for effective medical management and quality improvement services. They are also…
Remember Martin Shkreli, the indicted former CEO of Turing Pharmaceuticals, who increased the price of HIV treatment 5,000%, from $13.50 to $750 a pill overnight? How could those who saw his image forget how this villain became even more dastardly when, to avoid incriminating himself, he invoked the 5th amendment, smirking before a congressional committee…
In a recent American Journal of Managed Care article – Mental Health Fraud Exacts High Human and Financial Costs – Andria Jacobs, COO of PCG Software, shares that the U.S. loses up to $20 billion a year to fraudulent practices in the mental health sector. The HHS Office of Inspector General and partners are making…
The United States loses approximately $100 billion each year to healthcare fraud. Up to $20 billion dollars are due to fraudulent practices in the mental health sector. One of the largest healthcare fraud cases in US history occurred in behavioral health–one of healthcare’s smallest sectors. Like home care , this arena requires the utmost in…
One of the primary drivers of healthcare waste is administrative inefficiency. While the industry implements remedies and solutions with electronic prescriptions and electronic claims transfer and processing, the gorilla in the room that no one mentions is CMS. On December 28, 2015, we saw the first of several notices from the MACs that the Medicare…
Routinely waiving copays, coinsurance and deductibles is fraud Commentary: As healthcare costs continue to soar, shrewd employers continue to scrutinize ways to contain the cost of health insurance premiums to maintain a healthy bottom line and workforce and to create a competitive medical benefits package that attracts and retains the best and brightest staff. To…
To read the full article, visit cioreview.com
Consider the case of the Nurses Registry and Home Health Corporation, based in Lexington, Kentucky. Owner and Executive Director Vickie House owes $16 million to the US government for perpetrating widespread home healthcare fraud throughout her agency. Nurses Registry engaged in systematic false billing, violating the federal False Claims Act. The staff falsified medical records…
PCG Software Releases Primer on the Coding Modifier 59 Subset: XE, XP, XS and XU Primer provides guidance on new modifiers to alleviate confusion, denied claims in industryLAS VEGAS – November 3, 2015 – PCG Software (PCG), a leading provider of software solutions designed to slow the escalating costs of healthcare, today announced the public…
The number of nurse practitioners (NPs) in the United States has doubled in the last decade, from 106,000 in 2004 to 205,000 in 2014, according to the American Academy of Nurse Practitioners. Similarly, the number of physician assistants (PAs) grew 219% from 2003 to 2013, according to the National Commission on Certification of Physician Assistants.…
Medicare and Medicaid billing fraud scams—upcoding and unbundling schemes, double and triple billing, phantom billing and illegal kickback schemes —cost the United States an estimated $100 billion annually, inflating the size of government, escalating healthcare costs and burdening taxpayers. To combat the scams, the US government amended the Federal False Claims Act, adding the qui…
As co-pays and deductibles in Medicare and commercial health plans become more prevalent, so, too, does the temptation to waive them. But beware. If providers routinely waive forms of cost-sharing, such as co-pays and deductibles, or advertise “no out-of-pocket costs,” or “insurance-only billing,” they not only hurt their practice’s financial health, they may be committing…
On January 1, 2015, the Centers for Medicare & Medicaid Service (CMS) introduced 4 Healthcare Common Procedure Coding System modifiers, known collectively as the – X(EPSU) modifiers, as a subset of Current Procedural Terminology (CPT) modifier 59 (distinct procedural service). Modifier 59 is the most commonly used and abused modifier for Medicare reimbursement of CPT…
On April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) became law. Among its provisions, the law touted a permanent “doc fix” that repealed the sustainable growth rate (SGR) formula, which triggered annual automatic fee schedule cuts in Medicare physician pay and temporary Congressional patches. Designed to improve physician payment, MACRA…
Slightly ahead of schedule CMS released to the MACs and their website the revised Medicare Physician Fee Schedule. We know that one of the MACs, Wisconsin Physician Services (WPS) has also released their regional fee schedules. The CMS website has a new fee schedule that is labeled exactly the same as the deleted files but…
When CMS has an issue, we all have an issue. The latest problem concerns the Medicare Physician Fee Schedule database (MPFSDB). The fee schedule was released in November in the Federal Register but now has been cancelled by CMS for correction of unspecified errors. National Government Service and NHIC, MACs, have announced they are holding…
PCG Software CEO Michael Lubao was chosen as one of the top MGMA thought leaders by Senior Editor Roberta Mullin of HITECHAnswers and Healthcare NOW Radio, and was featured in a podcast interview at the October 2014 show. The podcast, which focused on how PCG Software’s provider suite of products can add extensive value to medical practices, can be found at…
Data analytics may be a hot item in healthcare conference exhibit halls this year, but revenue cycle management products also had a strong showing at this week’s MGMA Annual Convention in Las Vegas. Vendor announcements of new products and services included: PCG Software for 20 years has sold the Virtual Examiner cost containment software…
LAS VEGAS – May 13, 2014 – PCG Software, a leading provider of software solutions designed to slow the escalating costs of healthcare, today announced that it has achieved Gold Partner status in Oracle PartnerNetwork (OPN). By attaining Gold level membership, Oracle has recognized PCG Software for its commitment to establish Oracle-related knowledge in delivering…
In Health Management Technology magazine, PCG Software’s Michael Lubao provided extensive insight in his evaluation of the new revenue integrity technologies, and how today’s health plans and payers are more effectively controlling costs and identifying fraud. To read the full article, click here.
PCG Software customer Donna Levigne of Naperville Health Care Associates was front and center for her investigation of the financial challenges of her organization. She describes how Virtual Examiner played a starring role in this feature coverage in Healthcare Informatics magazine. Read the full article here.
PCG Software’s Andria Jacobs takes on fraud and abuse in a recent Compliance Today magazine issue. The feature coverage focused on how compliance officers can make a difference. Read the full article here.
Andria Jacobs of PCG Software again steps up to provide counsel on how to mitigate the $100 billion in fraudulent and abusive claims each year. The feature coverage appeared in Managed Healthcare Executive. To read the full article, click here.
PCG Software’s Andria Jacobs examines how claims adjudication enhancements fight fraud, reduce and contain costs, which add up to a bigger bottom line for payers. The feature coverage appeared in Healthcare Informatics magazine. To read the full article, click here.
Andria Jacobs examines the importance of employing quality improvement and collaboration with payers in this feature article in New Perspectives magazine. For the full article, click here.
