Medicare Compliance & Reimbursement

Tip: Obtain a denial from Medicare so the claim can cross over.

Myth: You can't bill for a preventive visit for a Medicare patient who's passed their first six months.

Truth: Regular Medicare won't pay for a preventive examination except for the "Welcome to Medicare" exam for a new Medicare patient. But many Medicare patients may have other coverage that will pay for a preventive visit.

"Once the six months have passed, offices feel they cannot report the preventive codes to Medicare because they will not be paid," says consultant Maxine Lewis, with Medical Coding Reimbursement Management in Cincinnati, OH. But many supplemental policies will cover these preventive services, she reiterates.
 
Important: You can't obtain coverage for a preventive visit from a secondary carrier until you receive a denial from Medicare, Lewis points out. So you need to bill your carrier, and then submit the claim to the secondary afterwards.

There are two different types of supplemental coverage: a gap-filler, which simply covers Medicare copays and deductibles, and a secondary payor, which may offer more benefits, Lewis notes. Patients may receive secondary coverage as a retirement benefit, and it may cover preventive services.

Watch out: Medical offices often make the mistake of trying to collect cash from patients for preventive exams instead of billing Medicare because they (wrongly) assume Medicare won't cover the services.

The key is to know all of your local insurance carriers inside and out, and be familiar with what they cover, says Michelle Logsdon with Falcon Practice Management in Bayville, NJ.

For example: In New Jersey, the Blue Cross plan uses a prefix for patient numbers that tells you what kind of coverage the patient has. If the patient's number starts with YHR, the patient only has gap-filling insurance. But if the patient's number starts with YHI or YHP, then the Blues may cover other things.

The rules may be different for patients who are enrolled in Medicare HMOs. The Medicare managed care plans may offer more coverage for preventive services than regular Medicare, says Logsdon.