Colorado Senate Advances Public Option Health Insurance Bill
Colorado Governor, Jared Polis, has been in the news for his ‘roadmap’ to reduce healthcare costs. We now uncover the latest developments of a state-run health insurance option. This advancement is seen as a step toward universal healthcare, but only one part of his strategy for achieving universal coverage. Read the article below to learn more about the public option health insurance bill.nnColorado’s Senate advanced another piece of Democratic Gov. Jared Polis’ healthcare agenda on Tuesday by tentatively endorsing a study on creating a state-run health insurance option.nn
nnThe bill would direct state agencies to recommend a plan that would compete with existing private insurance plans and those offered on Colorado’s healthcare exchange. Another Senate vote sends the study bill to the governor. It’s already cleared the House on a bipartisan 46-17 vote.nnBackers say it’s designed to curb some of the nation’s highest insurance premiums in mountain and other rural areas. Fourteen of Colorado’s 64 counties have just one insurer for the individual market, and monthly premiums there can be $500 higher than in metropolitan Denver.nnThe so-called “public option” bill is one of several measures advocated by Polis to reduce health care costs and increase accessibility for Colorado residents. In Washington state, Democratic Gov. Jay Inslee has called for a state-based public option health insurance plan that he has called a “step toward universal healthcare.”nnPolis’ campaign for office stressed a variety of strategies for achieving universal coverage.nnThe first-term governor already has signed a hospital price transparency bill into law.nnMajority Democrats in the Legislature are expected to send him bills to create a state reinsurance program to help private insurers lower premiums; a prescription drug price transparency bill; and a bill to get the federal government’s permission to import cheaper prescription drugs from Canada.nnThe public option legislation directs the Department of Health Care Policy and Financing and the Department of Regulatory Agencies to present a proposal in November. The plan would assess costs, funding sources, necessary federal permissions and funding, consumer eligibility and who in government would run a plan.nnSupporters say enrollment could begin in 2020 and a plan could start operating in 2021. Sponsors include Sen. Kerry Donovan and Rep. Dylan Roberts, both Democrats, and Republican Rep. Marc Catlin.nnDonovan noted Tuesday that too many residents in her own district, which includes Aspen, Vail and Glenwood Springs, have to choose between health insurance and paying mortgages or other family expenses.nnRepublican Sen. Jim Smallwood, an insurance broker, questioned the wisdom of having government step in as a competitor. He noted that high rural premiums persist and are rising under a state health insurance exchange adopted under the 2010 Affordable Care Act.nn”Introducing the concept of a public cure for what is broken in Obamacare seems hypocritical,” Smallwood said.nnOriginal article published on modernhealthcare.com.
n the Code Spotlight, Welter Healthcare Partners aims to profile and discuss practice applications of the code, as well as pertinent guideline reminders. Allograft Coding 2019 saw several changes to CPT, three codes that were added to the Surgery code set are for Allografting.nnCodes 20932, 20933 and 20934 all include templating, cutting placement and internal fixation, when performed.n
nnFor example, say an internist performs an annual wellness exam and addresses a skin lesion during the same visit. If the physician doesn’t append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the evaluation and management (E/M) service for the lesion, most payers will disregard the E/M service and only pay for the annual wellness exam, says Elhoms.nnAppending a modifier when it isn’t warranted can also be costly. For example, an internist owns their own radiology equipment. If they append modifier -26 (professional component only) to each radiology service, they actually miss out on revenue, depending on the service, says Elhoms. For example, when appending modifier -26 to the CPT code for chest x-ray, single view (71045), physicians could lose approximately $13 for every test performed.nnElhoms cites the case of an internal medicine practice with its own radiology equipment that saw an immediate 60 percent increase in reimbursement simply by removing this modifier from the radiology CPT codes it reported.nnOn the other hand, when a physician incorrectly appends a modifier and subsequently receives payment, they could be subject to a post-payment audit. “I’ve seen so many recoupments regarding inappropriate use of modifier -25 that have put private practice physicians out of business,” says Elhoms. “There’s a false sense of security when it’s paid. Recoupment requests can come out of nowhere.”nnElhoms knows of one family medicine practice that couldn’t recover from a $250,000 recoupment after a payer audited the practice’s use of modifier -25 on E/M office visit codes when providers rendered osteopathic manipulation treatment (OMT) during the same encounter.nnThe payer alleged that the documentation didn’t support a significant and separately identifiable service, and the payer felt the OMT was part of the typical work associated with the E/M code and shouldn’t have been paid separately, she says.nnIs there anything physicians can do to collect the payment they deserve while also avoiding compliance risk? Here are six tips experts recommend:nn1. Know your payer policies.nJust because one payer accepts a modifier doesn’t mean all will, says Michael Miscoe, JD, founding partner of Miscoe Health Law LLC in Central City, Pa. For example, one payer might accept modifier -25 in all instances consistent with the CPT definition of “significant, separately identifiable” while another might not permit it at all for certain services (e.g. when a physician reports an E/M code in addition to a code for a pain management injection).nnTake the time to identify the modifiers each payer does—and doesn’t—recognize. “Check each payer’s medical policies for service-specific as well as general policies regarding separate reporting,” says Miscoe.nn2. Hire a certified coder.n
“Ideally, you would have at least one person in-house who can assist with modifiers and be proactive about monitoring denials and providing education,” says Elhoms. Another option: Keep a trusted compliance consultant on stand-by as questions arise, she adds.nn3. Focus on clinical documentation.nFor example, when physicians report modifier -25, their documentation must support the history, exam, and medical decision-making for two separate services, says Elhoms.nnThink of each service as a separate encounter even though they’re rendered during the same visit, she adds. For modifier -59 (distinct procedural service), documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.nn4. Take a closer look at your billing system.nDoes your vendor incorporate National Correct Coding Initiative (NCCI) edits and update these edits quarterly? If so, are you certain that each payer has adopted those edits in its reimbursement policies? Do templates or billing automation encourage modifiers when they aren’t warranted or omit modifiers that are required?nn5. Append each modifier to the correct code.nFor example, modifier -59 should accompany a procedure or service code but not an office visit E/M code. Always refer to the NCCI procedure-to-procedure edits or specific payer bundling rules when determining what procedure or service code should include this modifier.nnExample: When reporting an excisional biopsy and lesion destruction, append modifier -59 to the code for the lesion destruction. When removing an intrauterine device and inserting a Nexplanon during an office visit, append modifier -59 to the code for the IU removal. Modifier -25, on the other hand, is always appended to an E/M office visit code when supported by the circumstances of the encounter, says Elhoms.nn6. Know what to do if you run into payment problems.nConsider the following advice:nnBalance bill the patient. While most payer contracts don’t permit this, a physician who is not under contract with a commercial payer may have the option to do so if all other state statutory advance notice requirements are met. Physicians are not permitted to balance bill patients with Medicare, and some states are enacting statutes to limit exposure of patients to either non-covered service costs or disallowed amounts for services that are covered, says Miscoe.nFight the denial. If the payer hasn’t published a policy on modifier usage, physicians may be able to successfully appeal the denial by citing standard industry guidance (e.g., CPT definitions of various modifiers, the NCCI Policy Manual for Medicare Services, or even medical policies of other major commercial payers), says Miscoe.nNegotiate your payer contracts. Ask payers to accept modifiers in all or certain circumstances, says Elhoms.nnTaking proactive steps to ensure compliant use of modifiers pays dividends in the long run, says Elhoms.nnOriginal 
This is a 46-year-old black female. She had prolapsed uterus causing her pressure, but she also had 2 previous bladder repair procedures that we removed the mesh, removed the suture, gave her proper time of healing, give her Estring cream for re-estrogenizing the vagina, and then we decided to go ahead and repair this. So, the patient was prepped and draped in the usual manner. Observing all aseptic technique, she was given a general anesthetic and prepped and draped. We put in a uterine manipulator and a Foley catheter and then we turned our attention to the above. We put in 4 port sites. These port sites were docked to an X1 robot, 1 port was for the camera, 1 port was for the PK bipolar cautery and laparoscopic scissors of the port, and then we had an assist port. The patient was docked to the patient’s side-docking in a steep Trendelenburg position. Then, we turned our attention to the console.nnAfter the patient was docked appropriately, we want on inspecting and saw a large right ovarian cyst that we thought would need to be removed. We looked at the left side. The left side was totally normal. So, we started on the left side at the round ligament. This was cauterized with the PK and then laparoscopically we cauterized and then developed an anterior and posterior aspect of the broad ligament. Then, we looked at the infundibulum and in the ovarian ligament. This was cauterized until secure, and then, laparoscopically we used scissors for cautery as well as to excise the tissue. We skeletonized and want down to the bladder flap anteriorly and went posteriorly and then we skeletonized and saw the uterine vessels they were cauterized until secure.nnThen, we turned our attention to the right side, which was a large ovarian cyst. We took the right ovary by going through the infundibulopelvic pelvic 1igament, IP. This was cauterized and cut until secure and then we went up to the broad ligament inc1uding removing the fallopian tubes and then the round ligament. We excised anteriorly again to deve1op bladder flap posterior1y just to get down to the uterine vessels that were cauterized. Then, once they were cauterized and secure next our attention to pushing the bladder well off the cervix. By using the uterine manipulator, the caudal ligaments were secure and then we circumferentially removed the cervix and then we pulled it out the cervix.nnThe uterus and the right tube and ovary through the vagina, irrigated, and then we used the V-Loc running locked stitch to secure the cuff, running it forward and backwards for good hemostasis. AlloWrap was used to put on the cuff to prevent any adhesive disease, and then we put in a pain pump, On-Q pain pump for pain. This was put in without complications. Then, as my assistant was closing the port site and undocking the robot, I turned my attention to below.nnAt this point, the patient was still in the dorsal lithotomy position, 1.5 cm from the urethral meatus, we did do a vertical incision and removed that 1 stitch that was from a previous surgery and then undermined until we got to the operative fossa. This was done bilaterally and at the level just below the pubic ramus, but also below the obturator fossa and then we used the Co1oplast TOT, and we anchored it on one side to the left side first and then we made sure the sling was lying flat and at the center of the posterior urethrovesical angle and then the second right side was placed and without complications.nnWe secured it and tied it up with tension. Then, we cut the suture and then we reapproximated the incision with 0 and 3-0 Vicryl in a running locked stitch. We took out the catheter. There was no need for cystoscopy since we did not do a TVT or TOT. The urine was clear. There was no air into the Foley catheter. We discontinued the procedure. The patient was transferred to the PACU in satisfactory condition.
Healthcare costs have been an increasingly popular conversation among doctors, patients, insurance companies and even the government. Colorado Governor, Jared Polis is getting involved and proposing the potential of reducing healthcare costs in Colorado. Read the article below from KOAA News5 of his new plan.nnDENVER – Gov. Jared Polis and Lt. Gov. Dianne Primavera announced their plan to reduce healthcare costs for Coloradans Thursday morning in Denver.nnGov. Polis laid out his “Roadmap for saving Coloradans money on healthcare” in an announcement outside Denver Health.nnThe plan featured six main points, which Polis billed as short-term solutions to reducing health care costs.n