Managing a busy practice is no simple task – whether you are a solo physician, part of a large group practice or in an employed setting. CMS is here to help. We’ve assembled a set of resources to provide you with information you might need on a variety of topics to help you make you get the most from you practice.
National Correct Coding Initiative
Office of the Inspector General work plan webpage
OIG Compliance Program Guidance
Out of Network
Colorado statute that provides "full" payment for non-par services when insured is inpatient at a par hospital and was hospitalized by a par doctor. Intended to hold the insured harmless from out-of-network charges when hospitalized in a participating facility by a participating physician, and receives services from a non-participating physician that the insured did not choose, such as a pathologist, radiologist or anesthesiologist. See Consumer Protection Statute section 10-16-704
Physician Designation Programs: Colorado profiling law compliance worksheet
Practice Evolution Reality Check (PERC)
Prescription for a healthier practice: Protect your practice from inappropriate discounts
Prescription for a healthier practice: Claims revenue cycle
Use this tool to evaluate your practice's capability to submit claims efficiently and accurately; analyze health insurer payments for accuracy; and effectively address delays, denials and reductions in payment.
Prescription for a healthier practice: Eliminate manual workers’ comp and auto claims processing
Switch from a manual claims process to electronic billing or “eBilling” for workers’ compensation and auto claims, which will help your practice reduce administrative costs, receive timely acknowledgement of your claims’ status and reduce the time it takes to submit bills. By doing so, physicians get paid faster and eliminate most of the hassles involved with paper billing. The AMA has developed tools to help your practice automate medical billing for workers’ compensation and auto injury. Start with the AMA’s Property and Casualty (workers' compensation and auto injury) Toolkit.
Prescription for a healthier practice: Empower your practice with the National Managed Care Contract
Take advantage of this comprehensive managed care contracting resource, which is based on the most physician-favorable managed care laws and regulations from all 50 states and the District of Columbia. This advocacy resource and its accompanying supplements address many of the issues that arise in the managed care contracting process and in the subsequent business relationship between physicians and managed care organizations. Developed by the AMA and state medical association attorneys with expertise in managed care contracting issues and regulations, the National Managed Care Contract includes more than 70 pages of model provisions based on state law and is supported by hundreds of legal citations.
Prescription for a healthier practice: Fight for accurate payment by decoding payer ERAs
The AMA has developed a tool to help address the hassle of decoding electronic remittance advices (ERAs) to determine if a billed claim was properly paid. If your practice performs property and casualty (workers’ compensation and auto injury) e-billing and receives ERAs, the AMA’s Claims Workflow Assistant tool can help you understand and address payment adjustments from payers. You can look up the reason or remark codes that payers place on the ERA to find associated workflows that can assist you in addressing claim denials or non-payments. And, you can look up the reason and remark codes payers place on the remittance advice to explain how the claim was processed and determine what those codes mean. Then, you can follow the steps provided to ensure accurate payment. The Claims Workflow Assistant also provides template appeal letters that physicians can easily modify to use in their practices.
Prescription for a healthier practice: Get paid what you deserve for out-of-network services
The AMA has developed the educational resource “Out-of-network payment challenges for the physician practice” to provide your practice with resources to understand a third-party payer’s obligation for payment to out-of-network providers. The resource explains some of the payment challenges that arise when a physician who is considered out of network requests payment from a patient and/or health insurer.
Prescription for a healthier practice: Hold health insurers accountable for out-of-network services
For this month’s practice checkup, ensure that your practice receives payment for out-of-network services it provides. Start with, “Holding health insurers accountable for out-of-network services.”
Prescription for a healthier practice: Increase your practice’s efficiency
Prescription for a healthier practice: Know the cost of doing business with your payers