Medicare Reimbursement: The Ins & Outs of Medicare & Medicaid

medicare-reimbursementOne of the most important areas of otolaryngology management with regard to medical billing solutions is having a comprehensive understanding of Medicare reimbursement. Similar to a third-party provider, medical practices, clinics and hospitals must send patient claims to both Medicare and Medicaid for reimbursement. While these claims are very similar to everything that you would be used to with a typical provider claim, there are a few exceptions that should be considered.

The most notable would be that the claims do not go through a clearinghouse, but directly to Medicare and Medicaid because they are high volume payers. While this is beneficial because the claims can be paid at a faster rate, it can also be a stumbling block, as the practice becomes even more responsible for the accuracy and correctness of the claim. Medicaid and Medicare reimbursement relies on the abilities of your practice’s medical billing solutions to generate revenue. Concerns about the implementation of ICD-10 are recognized within the medical community, however the final date has now been set for October 2015.

Medicare Medical Billing Solutions
There is a lot of administrative red tape involved in the process of Medicare reimbursement. When a practice, clinic or hospital sends a claim to Medicare, the Medicare Administrative Contractor or MAC is the department that processes it. They evaluate each claim that is sent in to Medicare and then they put it through for processing. The entire process for Medicare reimbursement takes about 30 days. When you consider the volume of Medicare claims that are made on a daily or weekly basis, 30 days is not all that bad.

Medical billing solutions that bill for traditional Medicare reimbursement, which includes Parts A and B, follow the exact same protocol as they would for billing a private provider. They input all of the patient information, procedure codes, diagnosis codes, place of service codes, NPI numbers and pricing. Nearly all of this information comes from the “super bill,” which will be produced directly from the medical coder.

The use of manual forms for billing Medicare can cause a few complications. Medical billing solutions which rely on an authorized software program allow the billing department to enter the data and then use the software to directly transfer the claim to Medicare.

How Medicare Reimbursement is Paid
Medicare will directly pay the provider for the services that are rendered when a Part A claim is processed for Medicare reimbursement. However, with a Part B claim, payment could come from either the patient or Medicare, depending on who accepts the assignment of the claim in what is known as the classic 80-20 breakdown. Medicare would be responsible for 80 percent of the cost and the remaining 20 percent would be billed to the patient.

Additional complications come when medical billing solutions have to file claims for Medicare reimbursement based on Parts C and D. Practices are not allowed to bill Medicare for services that are provided to a patient that has Part C coverage, as it is actually a private insurance plan that is partly paid for by the federal government.

Medical billing solutions can file a claim directly to Medicare for Part D covered patients for prescription drugs or vaccines that are allowed, however if the practice is not a licensed Part D provider, the claim must be filed on the patient’s secondary insurance or assign the total directly to the patient if secondary insurance is not available or the service is not covered.

In some situations of otolaryngology management you will be notified that the assignment of the claim will be denied by Medicare and the payment responsibility will be given to the patient. In this type of situation, the patient is 100 percent responsible for paying for the services. Making sure that you have the right number for each patient is one of the biggest challenges faced by medical billing solutions for Medicare reimbursement.

Medicaid Medical Billing Solutions
Also affected by the upcoming implementation of ICD-10, it is important for otolaryngology management departments to have an understanding of how Medicaid works. In some situations, creating a claim for a Medicaid patient can be even more complex than for Medicare reimbursement. Billing regulations and requirements for Medicaid can vary on a state-by-state basis, so the forms and formats used by medical billing solutions will change as a result. It is important for your ENT practice to check with the Medicaid program in your state to learn what forms and requirements are used locally.

The claims that are filed for Medicaid are similar to the methods used for Medicare reimbursement on Parts A and B, as well as for a private provider. All of the information must be complete and accurate, just as with Medicare reimbursement, so it is important for otolaryngology management to be aware of coding requirements and prepare for implementation of ICD-10. It is important to note that Medicaid programs cover a wider variety of procedures and services than Medicare, so there are fewer exceptions.

Medical billing solutions need to be aware that Medicaid is the last payer to be billed for services and procedures. What that means is that the patient’s insurance plan, secondary insurance and any other coverage options must be billed before Medicaid.

MD Pro Solutions Can Help
If sorting through all of the codes, requirements and information necessary to get Medicaid or Medicare reimbursement is making your head spin, contact MD Pro Solutions. We specialize in providing medical consultation services to otolaryngology management and administrative departments and can help you make sense of it all. From the upcoming implementation of ICD-10 to basic claims filing for Medicare reimbursement and even outsourcing medical billing solutions, our team of experts are here to help. Give us a call at 508-946-1665 or use our online form to request information about our services. Auditing and reviews, credentialing services, account management and more are all available to practices that specialize in otolaryngology through MD Pro Solutions.