SCGhealth Blog

No Show Fees- Medicare and Medicaid’s Contradictory Policies

Wednesday, January 17, 2018

By Audrey Landers

Missed appointments, or “No Shows” as they are known among physicians, are a long-standing problem. Approximately 19% of patients will be no-shows, leaving an average of $195 worth of missed revenue per patient. The most popular way to encourage patients to show up and recoup losses from those who don’t is to charge for missed appointments. This is fine…if the patient is covered by Medicare. If they have Medicaid it’s another story. 

Rules for Medicaid:
Federal regulations dating back to 2004 state that physicians who participate in Medicaid must accept Medicaid reimbursement as “payment in full” (42 C.F.R. §447.15). The Centers for Medicare and Medicaid (CMS) has interpreted this to mean that physicians may not charge Medicaid patients no-show fees, stating that missed business opportunities are a part of being in business and therefore should not be charged for. This policy is completely different from the one they have for Medicare.

Rules for Medicare:
Medicare’s rules for no-show fees are fairly straightforward. Any physician who accepts Medicare may charge missed appointment fees to Medicare patients so long as they meet the following requirements:

  • The missed appointment policy must apply equally to all patients
  • The patient must be made aware of the policy beforehand
  • The fee amount must be the same for all patients
  • Medicare may not be billed, instead the physician must bill the patient directly

A full explanation of the policy can be found in Chapter 1, section 30.3.13 of the Medicare Claims Processing Manual. This policy became first became effective in October of 2007. 

CMS considers the no show fee to be a charge for a missed business opportunity, rather than a service. This is completely contrary to the previously stated opinion that, when referring to Medicaid patients, missed opportunities are an unavoidable part of doing business.

Another issue is to be had with the main rule in the Medicare policy, specifically their rule stating that the missed appointment policy must apply equally to all patients. If the policy must apply to all patients, does that prohibit physicians who see both Medicare and Medicaid patients from having a no-show fee?
SCG Health believes strongly that policies should be clear and leave no room for confusion. While we don’t necessarily have an opinion either way whether or not no-show fees should be allowed, we do hope that CMS will clarify their contradictory policies so that there is no confusion about what is and is not allowed.

Health Literacy -Do Your Patients Understand You?

Wednesday, January 10, 2018

By Audrey Landers

Health literacy is the combination of basic reading and numerical skills that enables someone to understand the health information and services needed for healthy decision making. 

99% of adults in the United States are literate, while only 12% are considered to be proficiently health literate with 14% being considered below basic. What causes this enormous gap? One cause is that the reading level which is required to considered to be literate and health literate are vastly different. In order to be literate a person must be able to read at some level, with no qualifying benchmark for how well they must be able to do so.

The majority of adults read at an eight grade level, with 20% reading at a fifth grade level or below. Meanwhile, most medical documents are written at a tenth grade level. This difference means that even well-educated adults can have difficulty comprehending healthcare and reality is even more grim for those who only have basic literacy skills. 

Those who suffer the most from low health literacy are often those with other disadvantages. Elderly patients who may have trouble with their memory or with understanding new concepts, non-native English speakers and those from low-income families are most vulnerable to the problems that low health literacy creates. Those who are health illiterate are more likely to have difficulty understanding (and taking) medications, less likely to participate in activities that promote wellness and are hospitalized more often.

What can you do to help?

While increasing health literacy may seem like David vs Goliath to most physicians, there are a few things you can do in your own practice to help give patients the opportunity to understand more about their health.

First, by learning how to identify those who may have extremely low health literacy, you can personalize the care you give them to their needs. Here are a few signs to look for:

  • The patient needs help to fill out forms
  • The patient puts off decision making and instruction reading
  • The patient is a chronic no-show
  • The patient has difficulty complying with medication and recommended lifestyle changes

Be aware of your language. Health literacy also refers to a patient’s ability to understand spoken language in medical settings. To make yourself understood in the exam room you should be aware that some words can have very different meanings and implications in “medicalese” verses common English. One example is the word “diet” which to a physician may just mean what food someone eats but to a patient it means going on a diet like atkins or paleo.

Be specific. How many times have you told a patient to “come back if you get worse?” What does “get worse” mean exactly? This question is disastrous when combined with a new prescription that could have side effects that would confuse a patient. Instead, give patients specific symptoms and signs to look for whenever possible.

Use the “teach back” method. After giving a patient instructions on how to perform a task or take medication, instead of asking if they understood you, ask them to explain it back to you. By using this method, you can gauge what the patient understands and will know what exactly they have trouble with if they aren’t getting something.

Make it easy. One common piece of advice for educating patients is to give them a printed handout with the information and instructions they need on it. As mentioned above, most healthcare documents are written at a tenth grade level, meaning that even if you give your patient information to take home they may not be able to fully understand it. To combat this, it is recommended that any patient education material should be written at the sixth grade level or lower. You should also include easy-to-understand pictures and graphics when possible. The US National Library of Medicine has a great guide for writing easy-to-read heath materials.

To give you a general idea of what grade-level writing looks like, I put this blog post through a readability checker and found that it is written at about the eleventh grade level.

SCG Health Mail Bag- Billing for Non-Covered Services

Monday, January 08, 2018

By Audrey Landers

One of the most important parts of what we do at SCG Health is client education. We are always eager to answer questions and help our clients navigate the sometimes murky waters of the medical industry. Recently, we received this interesting question:

“We are participating in Medicare and submit claims with the GA modifier for non-covered charges would fall under the “frequency limits.” Do we have to accept Medicare allowance, or can we bill the member our full charge for a non-covered service if an Advanced Benefit Notice is signed? “

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There are a few different components to this question, so let’s break them down. 

Depending on the case an Advanced Benefit Notice (ABN) may not be necessary. ABNs only apply to services that could be covered by Medicare, but the provider has reason to believe the claim may be denied. For example: the Centers for Medicare and Medicaid Services (CMS) may deny a claim for a service that is not medically necessary. In this case however, frequency limits draw a clear boundary set by Congress for what is and isn’t covered. You are not required to submit the claim to Medicare because it is an excluded service. You could use a (now retired) Notice of Exclusion from Medicare Benefits (NEMB). 

The difference between these forms is small but significant:

  • ABN- Informs the patient that Medicare may or may not pay for the service they receive, and if Medicare does not pay then the patient will be responsible.

  • NEMB- Informs the patient that Medicare will not pay for the requested service, and the responsibility of payment will fall on the patient.

On both these forms, you will write in an estimated cost for the patient to review. Whatever you write in this section is the appropriate amount to charge. The key is that the patient is given advanced notice of what to expect.

We think the real question here is “what amount should we use as the estimated cost on either an NEMB or ABN?”

The answer is that you should use the self-pay rate (not the actual and usual charge) for any service that Medicare will not charge. You should treat them as any other patient who is paying for a service completely out-of-pocket. Of course, we are assuming here that your self-pay rate is higher than the Medicare allowable.

We take great pride in being helpful and informative, if you have any questions, you can ask us or click the “Gina, Help Me!” tab at the top of our website.

We hope you will take the time to learn more about our educational services and view our events calendar. SCG Health typically holds one free webinar each week, so be sure to check the calendar for events you are interested in.

Gimme 15 Minutes- Pass-Thru Billing

Friday, January 05, 2018

By Audrey Landers

EDIT 1/15/18: This event has been rescheduled to Monday, February 5, 2018 at 12:30 PM EST. We apologize for any inconvenience this may cause for attendees.

Join us on Monday, January 15, 2018 at 12:30 PM for a free webinar event covering pass-through billing.

SCG Health founder and CEO Jen Searfoss will be discussing the general health plan reimbursement policy prohibiting pass-thru billing and practical solutions for medical practice managers.

If you are interested in this free event, you can register here. After registering, you will receive an email about how to access the webinar.

Won’t be available for the event? No worries! All our past webinars are posted to our YouTube channel. Keep an eye on our events schedule so you can keep your calendar free for the next one.

MIPS Measure#128- Help Your Patients Achieve Their New Year’s Resolutions

Wednesday, January 03, 2018

By Audrey Landers

Every Year in January people make New Year’s resolutions and every year the goal at the top of everyone’s list is to lose weight (It may even be your own resolution, I know it’s mine). It’s so common that this year media outlets have made a point of publishing lists of resolutions that have nothing to do with weight loss! The only thing more predictable than having weight loss as your New Year’s resolution is not sticking to it and forgetting about it by February, only for the whole cycle to start over again the next time you change calendars.

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Obesity is a national epidemic, and while no one wants to be told they have to lose weight, patients may be more receptive to your help during this time of the year. If you aren’t already, it’s also the perfect time to be reporting Merit-based Incentive Payment system (MIPS) measure #128: Preventive Care Screening- Body Mass Index (BMI) Screening and Follow-Up Plan.

MIPS measure #128 is the percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Those with a higher than normal BMI and those with a lower than normal BMI would both be considered outside of normal parameters. You can get 9 points for this measure by reporting 50-68.89%.

This measure does allow for exceptions, which can include elderly patients for whom weight change would complicate other health conditions or patients in an urgent medical situation where treatment cannot be delayed.


Performance  Service Provided 
 G8420 Performance Met 

BMI is documented within normal parameters 
no follow-up plan is required 

 G8417 Performance Met

BMI is documented above normal parameters 
a follow-up plan is documented 

 G8418 Performance Met 

BMI is documented below normal parameters 
a follow-up plan is documented 

 G9716 Exception 

BMI is documented as being outside of normal limits
a follow-up plan is not completed for documented reasons
 G8421 Performance Not Met 

BMI not documented 
no reason is given
 G8419 Performance Not Met 

BMI documented outside of normal parameters 
no follow-up plan is documented, no reason given 

For more information, you can view the entire measure here. This measure can also be reported through electronic clinical quality measures (eCQM) using CMS measure CMS69v5.

SCG Health's 2017 in a Nutshell

Monday, January 01, 2018

By Gina Clegg

2017 was a rough year for a lot of people. It was a year of growth, a year of terror, a year of wonder and a year of wondering what is going on. At SCG Health, things were no different. We too wondered what was going to happen in the world of healthcare. Even with the changes we continue to learn and grow to allow us to be the best minions that we can for our clients. 

For those of you who didn’t know, SCG Health was created in 2011 by our one and only Jennifer Searfoss. Can we get a WOOT WOOT!!! That means that this year SCG Health will be turning seven years old. In recognition of that birthday, I’m going to fill you in on seven things that happened to SCG Health and its employees in 2017.

  • Jen got married just after we finished reporting data for the 2016 reporting year. Yes, literally, right after. We finished reporting data on March 31, 2017, and Jen walked down the aisle to marry her wonderful husband on April 1, 2017. It was a beautiful ceremony full of love, laughter, family and friends.

  • Jen, Amanda and I flew out to Las Vegas to the Advanced Specialty Coding Symposium sponsored by Decision Health. What most people don’t know is that I don’t like to leave the tri-county area, much less the state of Virginia. This meant my first time on a plane! Unfortunately, we got off the plane and experienced one of the deadliest mass shootings in US history. I think that we at SCG Health have determined that it isn’t good for Gina to travel.

  • We grew up and moved into a bigger building. Our very own Value Marketing Specialist Nasir Abbas, got his first sunburn moving office cubicles.

  • We also got our new contracting specialist Audrey, who took an internship with SCG Health and impressed us so much we offered her a position. Bless her heart, she said “It’s my first big girl job!”

  • Our wonderful Shannon, through hard work and dedication became SCG Health’s very own CFO. It is great to see everyone grow up and do so much with their lives!

  • SCG Health is big on education. When we moved we looked for a building with enough room for our clients to be able to come onsite to our location and learn. Not only that, I received my Bachelor’s Degree in Health Information Management. With this, I can continue to help SCG Health grow as well as help you with correct and up-to-date information.

  • The biggest announcement for 2017 and the best to end with is that SCG Health is approved for as a QCDR for 2018! That’s right we are here to help with your MIPS reporting again.
We love working with you guys and hope you have a safe and happy New Year!

Gimme 15 Minutes- MIPS Low Volume Exception Explained

Friday, December 29, 2017

By Audrey Landers

Start the New Year off right and join us on Monday, January 8, 2017 at 12:30 PM EST for our first Gimme 15 Minutes webinar event of 2018!

Physicians may be exempt from meeting certain requirements in the Merit-based Incentive Payment System (MIPS) if they receive too few Medicare payments or too little reimbursement from the federal payor. Tune in to this free event to hear SCG Health founder Jennifer Searfoss' introduction to this Low Volume Exception, and what it could mean for providers in 2018.

If you are interested in this free event, you can register here. After registering, you will receive an email about how to access the webinar.

Won’t be available for the event? No worries! All our past webinars are posted to our YouTube channel. Keep an eye on our events schedule so you can keep your calendar free for the next one.

Don’t trash that! What you do with your records can come back to haunt you

Wednesday, December 27, 2017

By Marla Durben Hirsch 

If you don’t want to end up in legal hot water, make sure you have solid record retention policies – and that you follow them. 

California health system giant Sutter Health has learned this lesson the hard way. Several employers and labor unions sued Sutter in 2014 for charging inflated prices in violation of the antitrust laws. The lawsuit was recently designated a “class action” lawsuit, making the number of plaintiffs much larger. 

Sutter has now been found guilty of inappropriately destroying 192 boxes of documents in 2015 that were to have been evidence in the lawsuit. The documents were subject to a “litigation hold,” which means that they couldn’t be destroyed during the dispute. According to Sutter’s own record retention policy, the boxes weren’t slated to be destroyed until 2035. The plaintiffs asked the court to impose sanctions on Sutter. 

Sutter claims that the shredding was a mistake and routine, done on the spur of the moment. The judge didn’t buy it. He said that the shredding was intentional, that the individuals involved knew of the litigation hold, and that while sometimes it’s okay to destroy records early, there was “no good explanation for this specific and unusual destruction here.” 

There was also an incriminating email written by a Sutter employee that said, “I’ve pushed the button…I’m running and hiding… fingers crossed that I haven’t authorized something the FTC [the federal agency charged with enforcing antitrust laws] would hunt me down for.” Sutter claimed that the FTC reference was a “joke.” 

The judge was not amused. He ordered Sutter to produce back up tapes and may consider issuing an adverse jury instruction. Note that in many cases a court imposes money penalties on the offender; the plaintiffs in this situation didn’t request that. 

So how long do I keep this document?

What Sutter did crossed the legal line. But the rules regarding record retention are confusing, particularly in the complicated world of health care. 

For instance, the length of time a small business needs to keep a record for tax purposes depends on the action, expense or event which the document records. Some records need to be kept only three years; others indefinitely. And even once the deadline passes for IRS purposes, a business may still need to keep a document for other reasons, such as for insurance or creditor requirements. 

Health care records are governed by additional laws. HIPAA’s security rule requires that records containing patient protected health information be held for six years from the date of creation or date when it was last in effect, whichever is later. Hospitals need to retain a cost report for at least five years after the closure of the cost report. State medical record retention laws vary widely by type of medical record. They also typically have different retention periods based on the age of the patient (usually records need to be held for a time after the child reaches the age of majority). 

While it may be tempting to hold onto most or all records indefinitely, that’s not necessarily the best practice, either. For one, there’s the cost of storing them, particularly boxes of paper records. And there’s a risk. For example, if you hold onto medical records beyond the legally required time period and then suffer a breach, you have more records potentially compromised and more patients to notify. 

Record retention gets even more dicey if the records become relevant in an investigation or lawsuit and then can’t be destroyed. Even an innocent disposal may have negative consequences.


This is a particularly confusing issue for providers. Make sure that you:

  • Have record retention policies that comply with federal and state law. You may need to confer with your medical association or obtain outside help. 

  • Follow those policies; tread carefully if you’re going to change the rules midstream.

  • Remember that how you dispose records is also important. Lax disposal can subject you to HIPAA and other violations.

Still Confused?

For further explanation, please watch our Gimme 15 Minutes webinar on this topic or check out this infograph we've made.

ICD-10 Codes to Get You Through the Holidays

Monday, December 25, 2017

By Audrey Landers

I love the Holiday season, it is by far my favorite time of the year, but even I can admit that the traditions I look forward to are pretty strange. The period between Thanksgiving and Christmas can be a transformative time, the air takes on a surreal quality as people put up lights, spend entire paychecks on gifts for people they may not even like and cut down enormous trees only to attempt to keep them alive for just a few weeks inside their own homes. It only makes sense that the injuries that arise during this time of the year can be just as unique as the season itself. To help you get through the holidays, I’ve taken the liberty of pulling a few ICD-10 codes you may find yourself needing.

Y93.D1 Activity, Knitting or Crocheting
From scarves to sweaters, as grandmothers and hipster millennials across the country rush to finish their homemade presents, don’t be surprised to find a few with knitting-related injuries in your waiting room.

R46.2 Strange and Inexplicable behavior
In families that celebrate Christmas, mothers may find that their children are acting a little different. They put their toys away, eat all their vegetables, and may even vacuum the living room without being asked! Surely something must be wrong. Not to worry though, Timmy and Susie are just doing their best to make sure they end up on the Nice List this year.

Z63.1 Problems with relationship with in-laws
It’s a stressful time of the year, and can put a huge strain on relationships. From unexpected extended stays to missed Christmas brunches. You can’t get through the season without someone’s feelings getting hurt.

R45.4 Irritability and anger & Y92.810 Car as the place of occurrence
Road rage happens all year round but it is exacerbated by holiday travel. Drivers will be getting angry everywhere you go: from the grocery store, to the mall and especially at the airport. 

W13.2XXS Fall from, out of or through roof
Some people get serious about their holiday lights. As houses everywhere begin to brighten up, don’t be surprised if you have one more patients come in needing to be patched up after trying (and failing) to add one more string of lights to the gutter.

W20 Struck by thrown, projected or falling object
When I was younger, my best friend’s only brother got his nose broken when he took a snowball to the face. This code will remain relevant throughout winter as the snow continues to fall, and kids continue to pack it into projectiles.

Z62.891 Sibling Rivalry
Parents will do their best to keep the kids from getting at each others’ throats but things happen. Maybe they miscounted and William got one more present than Peter or perhaps Kelly is mad because her cookie isn’t as big as Rachel’s. Fights will happen, and kids can be pretty brutal both emotionally and physically.

W55.32X Struck by other hoof stock
Santa and his flying reindeer probably don’t follow traffic laws. If your patients aren’t careful on Christmas Eve they could end up like the grandma in the famous song.

Is the lackluster response to a records request a violation of the False Claims Act?

Wednesday, December 20, 2017

By Marla Durben Hirsch

A new False Claims lawsuit deserves some special attention. It’s delving into somewhat new territory and may potentially lead the way for a multitude of similar lawsuits around the country. 

The whistleblower lawsuit, filed by a personal injury/medical malpractice law firm, alleges that more than 70 hospitals in Indiana have violated the False Claims Act because they falsely attested that at least 50 percent of electronic Medical record (EMR) requests by or on behalf of patients were responded to within three business days, a requirement of “Core Measure 11” of the Meaningful Use EMR Incentive Program. The whistleblowers say that the hospitals didn’t meet this 50 percent requirement, and thus wrongfully received nearly $325 million in Meaningful Use bonuses. 

This lawsuit is noteworthy for several reasons: 

  • There is increased concern that providers and EMR vendors took advantage of the Program. The Meaningful Use Program, created in 2009 as part of the HITECH Act, offered billions of dollars in bonuses to eligible hospitals and professionals if they used their EMRs to meet the requirements. As a result, many providers and EMR vendors jumped on the bandwagon. Now that the Program has matured we’re beginning to see the fallout. This year we’ve already seen eClinicalWorks agreeing to pay $155 million to settle claims that its software didn’t meet the Meaningful Use certification requirements, and 21st Century Oncology agreeing to pay $26 million to settle claims that it falsely attested that it met its Meaningful Use mandates. This is just the tip of the enforcement iceberg.
  • It points to the potential difficulty in meeting this Measure of the Meaningful Use Program. The Program requires that providers use Consolidated-Clinical Document Architecture (C-CDA) as the standard for building electronic clinical documents. Meaningful Use adds data requirements, which can be layered on top of C-CDA document templates to achieve Meaningful Use compliance. However, it can be argued that this system doesn’t work very well for Core Measure 11 and isn’t overly helpful for patients or providers. While Meaningful Use requires the patient information to be electronically generated and provided to the patient within three business days, the C-CDA is not a complete medical record, only accounting for demographic data and a small amount of health plan information, and often requires that the requested information to be pulled by hand and then put into the form requested by the patient. This can take longer than three days. Note that HIPAA itself allows a provider 30 days to comply with a patient’s request for his/her records. And this is just one measure. Providers can easily trip up on other requirements of government reporting programs. 
  • These are not your typical health care whistleblowers. Usually the whistleblower is a disgruntled employee or ex-employee who has inside knowledge of improper activity. Here, the whistleblowers are malpractice attorneys who got frustrated with the hospitals’ slow responses to their requests for patient records and decided to do a little digging. And this is just one law firm in one state. If they’re successful, imagine the floodgates opening. 

It will be interesting to see what kind of defense the hospitals will mount. Does an outside law firm have standing to be a whistleblower? Did the hospitals actually meet the Core Measure 11 50 percent threshold, just not with the law firm’s clients? Was Core Measure 11 impossible to meet? Is the EMR software to blame? Is the hospitals’ “release of information” provider, who is also a named defendant, the entity who’s at fault? Something else? 

It will also be interesting to see if this launches a government investigation as to whether the hospitals met the Meaningful Use standards or have to repay those incentive payments. 

It may make more patients questioning how their record requests are being handled. 

Takeaway: Providers should expect more scrutiny as to whether they were entitled to an incentive payment from the government. Be prepared to demonstrate that you earned that bonus you received. And don’t attest that you met a requirement when you really didn’t. It’s likely that it will come back to haunt you.

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