Medicare Compliance & Reimbursement

Don’t forget about Medicare Secondary Payer rules.

Pocket these tips to make patient insurance verification and eligibility determination a breeze.

Terry A. Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMC, QMGC, QMCRC, QMPM, a healthcare coding and billing consultant based in Laguna Beach, California, suggests the following best practices.

• Check to see whether the plan is active. This is especially important now that the Affordable Care Act (ACA) has gone through so many changes; a lot of the private plans available through the healthcare marketplace aren’t necessarily valid or active at this point, Fletcher notes.
• Ask the patient whether there have been any recent insurance changes or if there will be any changes in the near future.
• Find out whether the patient has coverage from multiple insurance companies — and check whether the patient has updated their coordination of benefits with each payer.
• If the patient is 65 or older, check whether they use Medicare. For example, some people are eligible for Medicare — but still use a plan provided by an employer or are covered in other ways through private insurance. Depending on the circumstance, this could denote a Medicare Secondary Payer (MSP) situation and needs to be billed carefully to avoid denials.
• Check whether the patient needs prior authorization or a referral for the specific service they’re seeking. Bonus tip: When you go through the effort to confirm these types of details with a particular payer, make a list, so you’re not verifying the same information over and over, Fletcher says. Most payers keep these policies for a while, and you can designate a person and timeline for checking the payer’s website and policies to see whether they’ve made any changes.
• Understand if the patient’s coverage includes diagnostics, procedures, or both. This is especially important in situations involving newer technologies used in some procedures.
• Check for benefit limits and frequency guidelines, as some plans have ceilings on costs or visits or services.
• Know whether some services, such as services surrounding behavioral health, mental health, or substance abuse, have particular payer requirements.
• If the patient is a Medicare beneficiary and a service or item isn’t covered, make sure you explain the reason why the Centers for Medicare & Medicaid Services (CMS) won’t cover it. Your next step should be to get an Advance Beneficiary Notice of Noncoverage (ABN) on file — and to provide a signed copy to the patient.
• Make sure patients know their responsibility for payment, especially for self-pay patients who require good faith estimates under the No Surprises Act.