Medicare Compliance & Reimbursement

Hint: Understand the rules for non-participating providers.

Learning all there is to know about Medicare compliance and reimbursement can be daunting, even for the most seasoned physicians. And that’s why, if you have a new provider in your office, you can expect it to take some time before they know the ropes. But that training period can be made a bit simpler with a few quick tips.

Check out the following five pointers that can help guide new Medicare providers toward coding bliss, courtesy of Arlene Dunphy, CPC, and Michele Poulos of NGS Medicare, during the Part B payer’s May 16 webinar, “New Provider/Front Office.”

1. Know How Medicare Works

Traditional Medicare pays 80 percent of the allowed charges, and the patient makes a 20 percent copayment, Dunphy said during the call. A deductible and coinsurance apply in most cases, and patients pay a monthly premium.

Medicare’s deductible this year is $183, which means the first $183 of approved charges for medical expenses are the patient’s responsibility, she said.

2. Decide Whether to Participate Or Be Non-Par With Medicare.

“Participating providers have an agreement on file to accept assignment on all Medicare patients,” Dunphy said during the presentation. “They accept the Medicare-approved charge amount and collect only the deductible and coinsurance amounts for covered Medicare services.” Participating providers collect a higher amount than non-par providers because they aren’t subject to the limiting charge, she added.

Non-participating providers, on the other hand, face a limiting charge and collect 95 percent of the fee schedule amount.

3. Don’t Resubmit Claims If Payment Takes A Few Weeks.

Although sometimes you’ll collect for your claims quickly, that isn’t always the case, and if payment takes more than a few weeks, you shouldn’t just resubmit claims and hope to get paid faster.

“Allow 29 days for paper claims and 14 days for electronic claims to be processed,” Dunphy said. “Electronic claims submitters should check your EDI validation report to verify claims were received and accepted, and check your software system to verify claims are not set up for automatic rebill every 30 days.”

4. Accept That Today’s Fee May Not Be Tomorrow’s

Medicare sets its fees through the annual fee schedule, but what you collect this year may change when the new year rolls around. “The fee schedule changes year to year and is approved by Congress,” Poulos said.

Some years, fees will go up for particular procedures, but the opposite has been known to happen as well, so keep a close eye on the fee schedule every year when the new version comes out.

5. Be Ready to Scrutinize LCDs

The regional Medicare Administrative Contractors (MACs) publish local coverage determinations (LCDs) that outline the specific information needed to submit a claim, Poulos said. “The LCD covers the indications and limitations of treatment, the primary and secondary ICD-10 codes supporting medical necessity, documentation requirements, utilization guidelines, frequency, and billing guidelines,” she said. Therefore, it’s in your best interest to know the LCDs for the services you perform most often very well.