Accurate billing and shadow-billing are critical

Fee-for-service physicians are paid for each insured service when billed correctly and in a timely manner.

Physicians paid by APP are required to shadow-bill clinical activity as an accountability measure of their contract. Shadow-billing accurately can provide valuable information for future health services planning. 

Physicians who shadow-bill should submit claims for all billable activities using the fee codes and preamble rules outlined in the MSI Physician’s Manual. Physicians on APPs can increase their income by 5.6% when they shadow-bill at least 80% of the contract amount each year. Shadow-billing more than the contract value will also result in a top-up equal to the difference. Some codes are paid on top of the APP contract rate, such as chronic disease management and clinical geriatrics assessment codes.

Billing/shadow-billing and the pilot project

• The model pays a per-patient rate for care provided over the year and a fee-for-service component equaling 30% of in-scope services billed (and 100% fee for service for all out-of-scope services billed). The pilot project will compare current payment models against the funding methodology to ensure it is a comparable payment model option. This methodology uses data provided through billings/shadow-billings to calculate and/or adjust the base capitation rate and sex/age ratios. Accurate billing/shadow-billing data is key to the success of the pilot and integral to accurate calculations.

• Physicians are eligible for a top-up if the funding methodology would have paid more than their current funding model. Failing to claim all insured services will have a material impact.

Billing reminders

• Bill for it all: Make sure you are billing/shadow-billing for all insured clinical services provided to patients.

• Stay informed: Subscribe to and review new MSI Physicians’ Bulletins, which provide updates on changes to billing rules and fee values. 

• The right code for the right service: Choose the code that reflects the work you do. For example, submitting a claim for an 03.03 office visit rather than an 03.03B complex care visit undervalues the work done, which reduces income/the ability to reach shadow-billing thresholds.

• Submit your billings/shadow-billing promptly: Holding and entering claims in batches can lead to increased errors/omissions or missing the 90-day submission deadline. 

• Details matter: Enter all relevant details for each encounter (modifiers, time stamps, etc.) and ensure charts include all documentation required for that code.

• Monitor regularly: Regularly monitor for rejected claims and make necessary revisions and resubmit for payment. 

• If in doubt, reach out: MSI can provide advice on how to bill a service encounter properly. Submit questions by email  for reference and for audit purposes.

• On-demand billing videos: DNS has created videos from a recent billing seminar, divided by chapters, to support physician billing.