Medicare Compliance & Reimbursement

Health Insurance Portability and Accountability Act (HIPAA) laws were created to prevent your patients' protected health information (PHI) from getting into the wrong hands, but at times, the privacy laws may throw a wrench into your relationship with your billing company.

The scenario: You receive a denial from your Medicare Administrative Contractor (MAC) but you are unclear about the service code on the Explanation of Benefits (EOB). You ask your billing company to get to the bottom of the denial, and their representative phones the carrier.

However, the MAC refuses to speak with your billing company rep, citing HIPAA laws that prevent them from discussing your patients' private information with an outside entity.

First idea: Your billing rep might offer to send the MAC a copy of your business associate agreement, but not all MACs will let this type of form fly as an appropriate proof of a relationship.

"I suggested giving a copy of the business agreement to the Medicare rep and she wouldn't accept that," says Cheryl M. Crayden, CMC Medical Services in Orrville, Ohio. "She said it had to be on the provider's letterhead with the provider giving me permission to check on her claims."

Requirements vary from one MAC to another, but most will accept a written directive from the medical practice (on letterhead) giving the billing company permission to communicate directly with the MAC regarding the practice's claims. Some carriers require you to notarize the letter before they'll accept it.

Be proactive: You can head off the problem by designating your billing company on your enrollment form when you first enroll with Medicare, says Cyndee Weston, executive director of the American Medical Billing Association in Davis, Okla.

"Providers designate their billing agency information on the enrollment forms (the 855-I) by completing sections 8 and 13 with the billing company information," Weston says.

"Updated forms are supposed to be on file and if that information changes, it must be updated."

Tip: If you ever sever ties with a billing company, or if they go out of business or change hands, remember to revoke their authorization with your MAC.

Editor's note: To get a copy of the Medicare 855 form, visit: www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf.