HOW TO DO BILLING FOR MEDICARE AND MEDICAID?

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HOW TO DO BILLING FOR MEDICARE AND
MEDICAID?
Just like when you bill to the private
third-party payer, billers must send claims to
Medicare and Medicaid. These claims are very
similar to the claims youd send to a private
third-party payer, with a few notable
exceptions. When you claim for Medicare and
Medicaid, there is no need to go through a
clearinghouse for these claims, and it also means
that 100 clean claims submission. Make sure
youre familiar with the Medicare contractors
claim submission preference and submit claims
accordingly because Medicare is not going to
adapt to provider needs the provider does all of
the adapting! BILLING FOR MEDICARE Note that,
Medicare strictly adheres to the established
National Correct Coding Initiative (NCCI) edits,
along with procedure/medical necessity protocol.
In addition, its claims processing system is
highly refined. Any claim that is submitted with
errors or without the correct information does
not process. Centers for Medicare Medicaid
Services CMS, Through Medicare, sets the rules
for the country, but Medicare claims processing
happens in regional areas. CMS contracts with
private companies, called Medicare Administrative
Contractors (MACs), to process Medicare claims.

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HOW TO DO BILLING FOR MEDICARE AND
MEDICAID?
A provider who furnishes a service that Medicare
probably wont cover can ask the patient to sign
an advanced beneficiary notice (ABN). By signing
an ABN, the patient agrees to be financially
responsible for the service if Medicare denies
payment. If the provider doesnt offer the ABN or
the patient doesnt sign the notice before
services are rendered, the patient doesnt have
to pay for that service. When billing for
traditional Medicare (Parts A and B), billers
will follow the same protocol as for private,
third-party payers, and input patient
information, NPI numbers, procedure codes,
diagnosis codes, price, and Place of Service
codes. We can get almost all of this information
from the superbill, which comes from the medical
coder. Claims related to Parts C and D of
Medicare are relayed through a private insurer
and should never be filed through Medicare. You
wont file Medicare claims with Parts C and D
because private health plan carriers have
agreements with Medicare to receive a certain
amount per member every month. Part D of Medicare
coverage may change depending on the person
receiving care because coverage depends on the
drugs involved. Some drugs arent covered by Part
D at all. Thus claims filed through Parts C and D
of Medicare should be treated like any other
claim handled through a private health plan
carrier.
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HOW TO DO BILLING FOR MEDICARE AND
MEDICAID?
Only those providers who are licensed to bill for
Part D may bill Medicare for vaccines or
prescription drugs provided under Part D. If the
provider is not a licensed Part D provider, the
biller must assign that total directly to the
patient (or the patients secondary insurance, if
they have it, and if it covers that procedure or
prescription). If a biller has to use manual
forms to bill Medicare, a few complications can
arise. For instance, billing for Part A requires
a UB-04 form (which is also known as a CMS-1450).
Part B, on the other hand, requires a CMS-1500.
For the most part, however, billers will enter
the proper information into a software program
and then use that program to transfer the claim
to Medicare directly. BILLING FOR
MEDICAID Medicaid programs differ from state to
state medical billing for Medicaid is much more
complicated than Medicare. Some citizens eligible
for care in one state may not be eligible for
care in another state, or they may receive more
or less benefits depending on the state in which
they receive care. Billing codes claim submission
protocols, reimbursement rates, and other billing
information will vary by state.
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HOW TO DO BILLING FOR MEDICARE AND
MEDICAID?

• You will start the medical billing process for
  Medicaid by filling out a state claim form for
  the services and procedures covered. Most state
  Medicaid claim forms will be divided into main
  two parts information regarding the patient
  and/or the insured person and information
  regarding the healthcare provider.
• Be aware when billing for Medicaid that many
  Medicaid programs cover a larger number of
  medical services than Medicare, which means that
  the program has fewer exceptions. Medicaid is the
  last payer to be billed for a service. That is,
  if a payer has an insurance plan, that plan
  should be billed before Medicaid.
• References
• Department of Health and Hospital, State of
  Louisiana. Retrieved from http//www.lamedicaid.co
  m/provweb1/about_medicaid/tpl.htm
• Medicare Secondary Payer (MSP) Manual Chapter 3 -
  MSP Provider, Physician, and Other Supplier
  Billing Requirements. Retrieved
  fromhttps//www.cms.gov/Regulations-and-Guidance/
  Guidance/Manuals/downloads/msp105c03.pdf
• Earl Dirk Hoffman, Jr., Barbara S. Klees,
  Catherine A. Curtis. Overview of the Medicare and
  Medicaid Programs. Retrieved from
  https//www.ncbi.nlm.nih.gov/pmc/articles/PMC41946
  83/