“In many ways, Medicare is much easier than private insurance, but it has a language all its own.” I say this a lot.
Once you’re initiated into the Mysteries of Medicare, you’ll find that one HUGE advantage is almost NO time spent in lengthy Verifications of Benefits. Here we will discuss 3 Easy Steps – How to Collect from Medicare Clients.
Time IS money – and if you spend an hour or two each week verifying benefits, well, now you can use those hours to take two Medicare clients and make money instead! 
Medicare benefits are ALL THE SAME… As long as it’s Original Medicare!
In this blog, I’m going to cover Original Medicare, which in 2023 is now only about 50% of Medicare enrollees.
Medicare Advantage is seriously COMPLICATED – because it’s also private insurance! Learn how to spot -and AVOID – the pitfalls that result in no payment by registering for the upcoming webinar…
Therapists: Medicare Demystified! on Friday, May 19, 2023, at 10 am Pacific time.
Billing Medicare PART B – Collecting from Medicare Clients
Verify ELIGIBILITY – Step 1!
Someone calls you and says, “I have Medicare.” Your Billing Buddy’s first piece of advice is…
Just because they have Medicare, does NOT mean you will BILL Medicare!
(Remember – what I said about 50% of Medicare enrollees having Medicare “Advantage.”)
Fortunately, there is a way to verify with 100% accuracy whether a client is enrolled in Medicare Advantage (also known as “Medicare Part C”). Try getting 100% accurate results with private insurance…!!
Here are a few automated ways to get Original Medicare eligibility:
- Medicare’s telephone IVR (interactive voice response) system
- Portal operated by your Medicare contractor
- Your clearinghouse/software vendor
For the portal or software option, enter your client’s demographic data and Medicare # (NO DASHES OR SPACES), and that’s it!
What you get back will vary slightly in output format depending on the electronic intermediary used, but watch for any of these terms:
- Medicare Part C
- HMO Medicare Risk
- Capitated
- Medicare Advantage / Group Medicare Advantage
- Medicare + Choice (an old name for Medicare Advantage)
- Medicare Private FFS – (means Fee for Service – not the Internet/text acronym. Despite it being VERY appropriate…)
- The name of a private insurer
If present, these will appear close to the top of the eligibility return.
Once you have this information, you only need to scan for the presence or absence of these letters:
QMB (Qualified Medicare Beneficiary), which means no matter what, you cannot collect any money from the client. The QMB designation will appear next to any other insurance policies listed, also near the top of your results.
In addition, you can check the accumulations toward the Part B deductible if it’s near the beginning of the year. All Medicare eligibility summaries will contain this information – unless the client is QMB.
And be sure to check the coordination of benefits (filing order). Medicare CAN be secondary – it’s not always primary.
Getting eligibility errors? There are a few common scenarios. If you join us on March 10th for the Therapists: Medicare Demystified! webinar, you will find out what these might be and how to troubleshoot.
Supplement or Secondary? – Step 2!
Ask your client if they have one. Be sure to get ALL the client’s insurance cards (if you can). Most of the time Medicare will forward to the next plan – but not always. In Medicare-ese, when Medicare forwards the claim, it’s called a “crossover.”
Pro tip: Check your Medicare remittance. It will say at the bottom of the claim line:
MA18 ALERT: The claim information is also being forwarded to the patient’s supplemental insurer:
Send any questions regarding supplemental benefits to them.
Didn’t get the card or info about the plan Medicare forwarded to? It happens.
Here’s my tried-and-true workaround.
I set the patient bill date ahead about 30 days. If money comes in from another payer before that time, great! I now know what the next policy is, and I add that information off the EOB into my billing program.
If there is no payment after 30 days, do one (or both) of two things:
- Bill the patient or the power of attorney/guardian. It’s surprising how often a bill conjures up an insurance card that didn’t exist at the time of scheduling the appointment.
- Call the payer referenced on the MA18 line – give them the client’s name, DOB, and Medicare #. They may or may not be able to give you eligibility information. The payer may also have a portal that is configured to accept the Medicare number.
If you can get the correct policy information, send a paper claim with a copy of the Medicare EOB/ERA (electronic remittance advice) attached.
What to Collect? Step 3!
Medicare’s Part B benefits are very simple.
Each year the federal government announces the deductible amount (it is $226 in 2023), and then Medicare reimburses 80% of the allowable amount.
Decision Tree:
If the client has no other insurance…collect the deductible or 20% as indicated on the remittance. Once you know the allowable amount for each code, you can collect it at the time of service.
If there is another payer, wait for the secondary claim to adjudicate and then collect whatever is left over – if anything. In the webinar on March 10th, I’ll present some seriously effective shortcuts where you can find out EXACTLY what certain policies will pay – NO VERIFICATION NEEDED.
If you are a “nonparticipating” provider, you may also collect the 15% “limiting charge.”
If the secondary payer is Medicaid – BEWARE!
Federal law prohibits the collection of Medicare deductibles & coinsurance from QMBs, but not all Medicaid enrollees qualify for the QMB program.
If your client is not QMB but IS enrolled in Medicaid, you MUST check state Medicaid law before collecting.
MOST states forbid collection from Medicaid enrollees.
A few allow collection only for procedures the state Medicaid program does not cover.
When in doubt – call your state for clarification or do not collect money from a Medicaid-enrolled client.
Then there are times that Medicaid “covers,” but doesn’t actually pay!
Let’s say the Medicare allowable for the code billed is $115. For the same code, your state’s Medicaid program allows $85.
Medicare will pay 80% (which is $92, roughly, because of the sequester).
Since $92 is higher than the state’s allowance of $85, the state will conclude, when the claim reaches them, that you have been paid in full.
In this instance you will have to write off $23, you cannot collect it from the client.
These are not considered a “routine waiver” of patient responsibility, because there is no patient responsibility. The same is true even if you choose not to be a provider for Medicaid. Medicaid would cover the service if you chose to participate.
If you would like to schedule a consultation, please contact me today. I am here to help!
And that, my friends, is ALL there is to it.
Until next time,
Susan
AKA “Your Billing Buddy”
Click here now to Register
Therapists: Medicare Demystified!
on Friday, May 19, 2023, at 10 am Pacific time.
Find out how to bill Medicare for telehealth after the end of the COVID Public Health Emergency!
Need to learn how to read the Medicare fee schedule?
What is covered by Medicare, what should be in your records, and what do you do if you get audited?
