Ensuring Medicare and Medigap Reimbursement

by | Published on Nov 6, 2014 | Healthcare News

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Medicare does not cover all health-related services and medical supplies and pays 80 percent of allowed expenses. Enrollees must still pay Medicare copayments, deductibles and coinsurance amounts which make up the remaining 20 percent. Commercial health insurance companies offer Medigap or Medicare Supplementary Insurance to provide reimbursement for these uncovered out-of-pocket expenses. So verifying Medigap insurance is an important part of the eligibility benefit verification process in physician practices. Medical coding and billing also requires knowledge of the types of Medigap policies and coverage offered.

About Supplementary Health Insurance

There various types of Medigap policies which cover different types of conditions and come with a different set of benefits and amounts. Verification of coverage is a critical step in revenue cycle. It includes verifying personal information and insurance verification on all primary and secondary payers such as type of Medicare coverage (Part A or Part B), effective date, deductibles, coinsurance and other details. For patients with Original Medicare (Parts A and B) and a Medigap policy, Medicare would first pay its share of amounts it has approved for their covered health care costs. Their Medigap policy would then pay its share of the cost. Those enrolled in a Medicare Advantage plan are not eligible for a Medigap plan. Moreover, these supplements do not cover expenses that Medicare does not approve.

Non-verification of insurance can lead to claim rejections and denials. For Medicare supplement claim processing and reimbursement, physicians need to verify the following:

  • Demographic details
  • Eligibility, co-payment and coinsurance information
  • Secondary coverage in addition to Medicare eligibility prior to the patient encounter
  • If the secondary plan covers what Medicare approves but does not pay

Cross-over Claim Submission

Cross-over claim submission is when Medicare supplement policies accept claims directly from Medicare. The physician has to inform Medicare about patients with such Medicare supplement plans including the details of the plan and the effective date. After the claim is processed, Medicare would send it to the secondary payer which ensures proper and timely reimbursement for the physician.

For the cross-over of other types of supplementary policies, details that would need to be submitted would include the policy holder’s name, policy number, and name of the plan on the HCFA-1500 or UB-04 as well as the assigned Medigap number of the insurance company that issued the policy.

With automatic cross-over, the medical coding and billing team needs to know that errors on claims cannot be corrected. Moreover, automatic cross-over to the secondary payer would not occur in the case of claims that are totally denied, a duplicate claims, adjustment claims, claim reimbursed 100 percent by Medicare, claims submitted to Medicare after the eligibility date, or claims submitted by non-participating physicians.

For proper reimbursement, all these things should be considered before submitting the claims. However, doctors’ offices are very busy places and their staff would seldom have the time for matters relating to patient eligibility verification and claim submission. Relying on an outsourcing company with a team of trained and skilled coders, billers and insurance verification specialists would help physicians manage their revenue cycle efficiently.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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