Navigating Medicare: Coverage Essentials and Billing Tips

Medicare, first signed into law in 1965, was created to provide health coverage to Americans ages 65 and over. This federal health insurance program also covers certain younger individuals with disabilities or specific medical conditions. Today, there are more than 65 million people in the Medicare program. Medicare consists of several different parts, each providing coverage for specific healthcare services. Physicians that accept Medicare patients need to be familiar with the billing and reimbursement process. Outsourcing medical billing to a company that has experience in handling Medicare claims can ensure faster turnaround on claims and reduce risk of rejections.

Main Parts of Medicare

Medicare has different parts. While Medicare included only parts A and B when it was introduced, additional parts of have been added over the years to expand coverage. Today, Medicare has 4 parts: Part A, Part B, Part C, and Part D.

• Medicare Part A (Inpatient/Hospital Insurance): Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services.
  • Inpatient hospital care covers up to 90 days each benefit period plus 60 lifetime reserve days for patients admitted into a general hospital and also coverage of 190 lifetime days in a Medicare-certified psychiatric hospital.
  • Skilled nursing facility care includes coverage for a range of services provided in a SNF, including administration of medications, tube feedings, and wound care. Individuals who qualify for these services are covered for up to 100 days each benefit period.
  • Hospice care refers to coverage for individuals who are determined terminally ill by a provider. Coverage is available for as long as the provider certifies the care is needed.
  • Home health care covers services for homebound individuals who need skilled care. They are covered for up to 100 days of daily care or an unlimited amount of intermittent care

Most people do not pay a premium for Part A if they or their spouse have paid Medicare taxes while working.

• Medicare Part B (Medical Insurance): Part B covers medical services and supplies that are necessary to diagnose or treat medical conditions. This includes:
  • Provider services: Medically necessary services provided a licensed health professional.
  • Durable medical equipment (DME):
  • Home health services
  • Ambulance services:
  • Preventive services:
  • Therapy services (outpatient physical, speech, and occupational therapy services provided by a Medicare-certified therapist)
  • Mental health services
  • X-rays and lab tests
  • Chiropractic care when manipulation of the spine is medically necessary to fix a subluxation of the spine (when one or more of the bones of the spine move out of position)
  • Select prescription drugs, including immunosuppressant drugs, some anti-cancer drugs, some anti-emetic drugs, some dialysis drugs, and drugs that are typically administered by a physician

Part B requires a monthly premium.

• Medicare Part C (Medicare Advantage): Most Medicare beneficiaries receive their health coverage through Original Medicare; however, some opt for a Medicare Advantage Plan, also called Medicare private health plans or Part C. Medicare Advantage Plans collaborate with the federal government and receive a set payment per person to deliver Medicare benefits. Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS) are the most common types of MA Plans.

Individuals who choose to enroll in an MA Plan continue to have Medicare coverage. Consequently, they typically pay a monthly premium for Part B (and, if applicable, a Part A premium). Moreover, those who are part of an MA Plan receive the same benefits available under Original Medicare.

• Medicare Part D (Prescription Drug Coverage): Part D provides coverage for prescription drugs. It can be added to Original Medicare (Part A and Part B) through standalone Prescription Drug Plans (PDPs) or as part of Medicare Advantage plans that include prescription drug coverage. All Part D plans must include at least two drugs from most categories and must cover all drugs available in the following categories:
  • HIV/AIDS treatments
  • Antidepressants
  • Antipsychotic medications
  • Anticonvulsive treatments for seizure disorders
  • Immunosuppressant drugs
  • Anticancer drugs (unless covered by Part B)

Part D plans must also cover most vaccines, except for vaccines covered by Part B.

• Medicare Supplement Insurance (Medigap): Medigap plans are private insurance policies designed to supplement Original Medicare (Part A and Part B) coverage. These plans can help cover some of the out-of-pocket costs, such as deductibles, copayments, and coinsurance that Medicare beneficiaries would otherwise have to pay. To be eligible for a Medigap policy, the individual must already have both Part A (Hospital Insurance) and Part B (Medical Insurance) of Original Medicare.

Every part of Medicare offers distinct coverage options and costs, allowing beneficiaries to tailor their healthcare coverage to match their specific needs and financial capabilities. Understanding the various parts of Medicare and how they interconnect to provide comprehensive healthcare coverage is crucial for the general public.

Physicians who care for Medicare patients must also possess a thorough understanding of Medicare billing considerations. This knowledge ensures accurate billing practices and compliance with Medicare regulations, promoting a seamless healthcare experience for both providers and patients.

Medicare Billing Considerations

Medicare billing considerations are important factors and guidelines that healthcare providers must follow when submitting claims for reimbursement from the Medicare program. Here are some key considerations:

Patient eligibility verification: Before providing any services to a patient, the provider must verify the patient’s Medicare eligibility. This ensures that the patient has active Medicare coverage and that the services provided will be eligible for reimbursement.

Covered services: While Medicare covers a wide range of medical services, not all are reimbursable. To avoid claim denials, providers must ensure that the services they render are covered by Medicare.

Coding and documentation: Medicare billing requires accurate and detailed coding and documentation of services rendered for appropriate reimbursement. Proper coding ensures that the services are accurately described and thorough documentation supports the medical necessity and appropriateness of the services.

Timely filing: Claims must be submitted within Medicare’s specific timeframes. Adherence to these deadlines is necessary to avoid claim rejection due to untimely filing.

Billing errors and audits: Providers must be vigilant to avoid billing errors as they can lead to penalties or recoupment of payments. Additionally, Medicare conducts audits to verify the correctness and appropriateness of claims submitted. Healthcare providers must be knowledgeable about Medicare regulations to prevent fraud and abuse in the billing process and avoid engaging in any fraudulent billing practices.

Advance Beneficiary Notice (ABN): In certain situations where Medicare is likely to deny payment for a service, healthcare providers must provide the patient with an ABN. This notice informs the patient that they may be responsible for payment if Medicare denies coverage.

For details on Medicare, visit: https://www.cms.gov/medicare/medicare

Every part of Medicare offers distinct coverage options and costs, allowing beneficiaries to tailor their healthcare coverage to match their specific needs and financial capabilities. Understanding the various parts of Medicare and how they interconnect to provide comprehensive healthcare coverage is crucial for the general public.

Physicians who care for Medicare patients must also possess a thorough understanding of Medicare billing considerations. Partnering with a professional medical billing company is a viable strategy for providers to ensure proper reimbursement, compliance with regulations, and a positive relationship with Medicare and their patients.