Navigating Medicare Billing Guidelines

Is navigating the Medicare billing guidelines confusing you?

At Physicians Revenue Group, Inc., we have had numerous concerns from medical practices we have worked with. The good news is that while the Medicare billing guidelines seem intimidating at first glance, they are rather straightforward once you get the hang of it. We have offered third-party medical billing services for over two decades and have helped countless practices with CMS rules and regulations.

First, let’s discuss CMS briefly and what your practice needs for submitting claims via CMS.

CMS and Medicare Billing Guidelines

There are five essential things that a practice needs to submit claims via CMS:

CPT codes of every program you are managing for patients
Dates of service
Provider names
Place of service
ICD-10 codes in relevance to the condition being managed under a program

Additionally, this is not necessarily required but can come in handy if/when you are audited:

Care managers assigned to patients

This information is relatively easy to locate while managing a care coordination program.

Importance of Medicare Coverage Analysis

The Medicare coverage analysis minimizes errors, helps remove patient dissatisfaction, and promotes and streamlines billing compliance and many other benefits.

Decreasing Potential Errors

Medicare coverage analysis decreases the risks of improper and inappropriate billing. The False Claims Act is triggered by fraud violations owing to inaccurate billing. When running billing operations complying with federal regulations, your practice can sidestep the risks of paying criminal and civil penalties.

Navigating Patient Dissatisfaction

Frequently, patient dissatisfaction and undue financial obligations run hand in hand. There can be double billing for billing the CMS or third-party payors. These can be for services that the sponsors have already paid for. This will lead to unhappy patients, who undergo financial burdens as they keep receiving additional and incorrect service bills. All of this ultimately affects the reputation of a medical practice/institution. Such instances are often indicators of billing problems and processing issues. This is why it is vital to evaluate and assess trends and recognize such issues by understanding the sequence correctly from the Medicare Coverage Analysis assessment. Medicare Billing Guidelines also include the:

Streamlining and Promotion of Billing Compliance

Furthermore, the Medicare Coverage Analysis assists in coordinating administrative and billing activities. It also helps with the downstream communication of the billing staff and other research team members. This helps reduce the hours spent reviewing charges and providing the necessary roadmap – eventually, it works in harmony to streamline billing compliance.

Vital Steps Towards Medicare Claim Management

There are efficient and easier ways to address the common billing challenges:

Automation of Eligibility Checks

The first step is to actively verify the discharge dates with the eligibility results to avoid the overlap of services with other providers and make sure you get timely reimbursements.

Leveraging Analytics to Meet Specific Needs

Your practice can stay on top of timely filings, admission notifications, and elections via a robust reporting system.

Making Medicare Understandable to Billers

A system playing on intuition is easy for cross-training staff; anyone in the billing office can submit error-free claims to Medicare in addition to any other commercial payer through the same system.

Fixing Denials

Next in navigating Medicare billing guidelines is understanding the top denial, rejected, and return-to-provider reason codes. This understanding goes hand in hand with fixing them on the front end to prevent recurrences. This is important for slashing A/R days and getting claims paid with the first submissions.

Final Word on Navigating Medicare Billing Guidelines

Studying denied and rejected claims gets frustrating, especially when your staff has to spend hours per week analyzing unpaid claims. This is in addition to analyzing EOBs to determine the necessary steps for correcting and reprocessing denied and rejected claims. It is also important to note that big aging buckets lead to chaos and lesser cash flows. At PRG, we offer benefits verification, patient eligibility, and other RCM solutions for effective and proactive billing. Our RCM and billing team is equipped with modern takes on Medicare billing guidelines, ready to help you get paid faster and assist in growing the financial health of your practice.

Frequently Asked Questions

What are ICD and ICD-10?

The ICD stands for the International Classification of Diseases, and the ICD-10 targets the Tenth Revision of the system, which is in use by healthcare providers. It is put to use for the classification and coding of symptoms, diagnoses, and procedures for claims processing.

How to respond to a denied claim?

Your billers can forward an appeal letter to the insurance provider stating why you believe the claim denial is wrong, thus, requesting the insurance company to reverse the denial.

Who uses CPT codes?

In addition to federal programs, including Medicare and Medicaid, the CPT codes are used throughout the USA. These are preferred systems for coding and effectively describing healthcare services.