Radiology Coding Alert

Enhance your Medicare knowledge that extends beyond the coding realm.

When working with a Medicare patient, you’ve got to take a lot of factors into consideration if you want to ensure your claim is going to get paid. But that’s not enough on its own. You’ve also got to know what sources of misinformation to avoid — and where to avoid them.

Check your knowledge against these assumptions, on the expertise of Patsy Schwenk of Medicare Administrative Contractor (MAC) CGS in a “Medicare Basics” webinar, so you know how to bill Medicare for the services your clinicians provide.

Myth 1: MACs Are Government-Run

Because Medicare Administrative Contractors (MACs) process your claims, you may think they’re owned by the government, but that’s not the case, Schwenk says. “The MAC is a private insurer that has been awarded a geographic jurisdiction to process Part A and Part B claims,” she maintains, adding that MACs are responsible for:

• Processing fee-for-service (FFS) claims,
• Making and accounting for FFS payments,
• Enrolling providers in the Medicare programs,
• Handling provider reimbursement services,
• Auditing institutional provider cost reports,
• Handling redetermination requests,
• Responding to provider inquiries,
• Educating providers about billing rules,
• Establishing local coverage determinations (LCDs),
• Reviewing medical records for selected claims, and
• Coordinating with CMS as well as other FFS contractors.

Myth 2: Medicare Is Applicable Only to People 65 or Older

Although Medicare does cover those who are 65 and older, it also covers certain beneficiaries under the age of 65 with disabilities, and those at any age with end-stage renal disease (ESRD). To qualify for Medicare, the beneficiary must be a U.S. citizen or lawfully present in the U.S. and must live in the U.S. for five straight years, Schwenk says.

Myth 3: MACs Make Statutorily Noncovered Services Determinations

Medicare covers medically necessary services, which means that the item or service is needed for the diagnosis or treatment of a medical condition. Examples are physicians’ professional services, diagnostic tests and X-rays, mental health care, physical therapy, and more, suggests Schwenk. There are also some statutorily noncovered services that are part of the Medicare program, and those are named by the Centers for Medicare & Medicaid Services (CMS) in the Medicare Carriers Manual — they are not determined by the MAC.

“I always say the noncovered items are things we never ever pay for because it’s actually written in the Medicare law that these are things we do not pay for,” Schwenk advises. Examples include acupuncture, cosmetic surgery, hearing aids, healthcare rendered outside of the U.S., and services not reasonable and necessary, she mentions.

Myth 4: Medicare Is Either Part A or Part B

In addition to Medicare Part A and Part B, the program also includes Part C and Part D, Schwenk indicates. The four elements are as follows:

Part A: Hospital coverage. “That would include inpatient hospitals, SNFs [skilled nursing faclilities], hospice, and some home health services,” she said.

Part B: Medical coverage. This includes “physician services, outpatient care, durable medical equipment, all of your preventive services, and some additional home health services,” explains Shwenk.

Part C: This is also known as Medicare Advantage (MA) plans. “These basically replace Medicare Parts A and B. A Medicare patient would not have Parts A, B, and C. Usually they would have either A and B or C. Advantage plans are Medicare-approved private insurance companies that offer all services and may provide prescription drug coverage and other benefits,” she notes.

Part D: Prescription drug coverage. “If someone has A and B or traditional Medicare, they will also have a Part D plan to help pay for their prescription drug costs. Usually a Part C plan includes prescription drug programs,” Shwenk says.

Myth 5: Medicare Advantage Is a Supplemental Policy to Medicare

Many people are confused about what exactly a MA plan refers to, Schwenk said. The reality is that the MA plans “are an alternative to the traditional A and B. They are not a supplement,” she explains.

With a supplemental policy, a patient is covered by Medicare Parts A and B, and then also gets a secondary, supplemental policy to pay for out-of-pocket costs that Medicare won’t cover.

An MA plan, on the other hand, replaces Parts A and B. “We get a lot of questions about Advantage plans, and we do not process those claims,” Schwenk says of the MAC. “Because it’s a replacement to Parts A and B, those claims do not go to a MAC. The claims go to the Advantage plan. Any questions you have for a claim processed through an Advantage plan has to go to that company.”

Myth 6: Medicare Beneficiaries Can Change Plans Whenever

Although Medicare patients do have the ability to change their insurance programs, they must wait until the enrollment period to do that. “Every year, a Medicare beneficiary can change plans between Oct. 15 and Dec. 7,” acknowledges Schwenk. “During this time, the patient can keep the same insurance if they want to, but if they’re in original Medicare, they can switch to an Advantage plan or vice versa, or they can switch to a different Medicare Advantage plan.”

Reminder: Coverage is effective the first day of the next calendar month. “So it’s very important, especially in November to February, to make sure you’re getting all their Medicare cards — everything in their wallets concerning Medicare — because it can change,” advises Shwenk.