What is Medicare/Medicaid?

Medicare and Medicaid

Medicare and Medicaid are the two government payers who make up the greater portion of which a medical biller and coder will work with to provide payments to the provider. They are actually very high payers every day and are the ones who set the standards for most coding and billing procedures in use for most commercial payers.

The Federal Insurance Contributions Act (FICA). This act funds the entire system of Medicare and the latter is the biggest government payer of all. This is done by deducting payroll taxes from all employed Americans who are employed. Enacted in 1935, this mandates a payroll tax on the employees’ paychecks together with contributions from the employers. This will fund the Social Security and Medicare programs of the country.

Medicare Eligibility

In general, those who are qualified for Medicare are:

1. Legal residents of the U.S. who are 65 years old and above and have paid FICA for 10 years.

2. Patients with end-stage renal disease

3. Individuals eligible for Social Security Disability Insurance and are suffering from permanent disability.

Medicare coverage is not uniform for all those who are eligible and therefore it has different levels of coverage, referred to as Parts.

Part A.

This is when it has already been paid through the taxes from the patient’s taxes. It covers patient care, short-term skilled nursing care facility, hospice, and home care. Basically, it is considered hospital insurance.

Part B.

The payment for this is via deductions. These deductions are usually from Social Security dividends. Its coverage includes physician and outpatient services, including outpatient facility fees and some fees for other medical necessities that are not covered in Part A like physical and occupational therapy. Annual deductible must be first met by the patients for Medicare to cover 80% of the expenses.

Part C.

This gives the opportunity to Medicare-eligible patients to enroll in Medicare replacement plans offered by private health insurance. These plans however must meet or even exceed the Medicare standard to be approved.

Part D.

This is rather new in the entirety of Medicare and aims to cover the prescription drugs of the patients. This will require the patients to be Part A and B qualified first and once qualified and enrolled, the patient must enroll in a prescription drug plan or a Medicare prescription plan. This however does not totally relieve the patient from complete financial responsibility.

For the patient, the coverage for Medicare is not that big of an amount but it is always there when you need it and is always reliable. For the provider, payments for the services offered, just like any other insurance company, will only happen if he is Medicare credentialed and approved. It may take some time for the provider to be approved but thanks to technology, everything can be done online via forms available on the CMS website. Basic requirements for registration include the providers’ Tax Identification Number and National Provider Identification (NPI). Once the registration is complete, the provider will be given a Provider Transaction Access Number (PTAN) to allow him or them (if it’s an organization) to check claims. Of course, those who are not Medicare-approved are not entitled to claims submissions and reimbursements. There are medical billing and credentialing companies that offers services to help providers get approved by Medicare. This is just one of the services that My RCM group offers and depending on the state, the complexity of the practice or institution, and the availability of the requirement, we can help the physician credentialed as fast as 14 days.

Contrary to the popular belief, Medicare registration does not automatically mean that he is a participating provider. What does this mean? For example, Provider A is registered in Medicare but “non-par” or non-participating. If a client or a patient seeks services from a provider, the provider is not obligated to receive a fee scheduled as full payment. Provider A can bill that patient or client full or charge up to a higher level called a limiting charge and therefore can bill and collect payment. Medicare reimburses only 80% of the fee schedule and the remaining 20% will be paid by the client/patient out of his pocket. This collection process is sometimes cumbersome and will become a receivable to the provider. Knowing this in mind, the provider can now decide if he will participate in Medicare and collect lower fees or take on the risk and challenge of collecting fees from his patients at a higher rate.

Claims Processing

Once everything is set and good to go, claims submissions can now be processed. A local Medicare contractor processes these claims following the guidelines and policies of Medicare. There are almost all codes for the services and procedures but in case there is none, the local Medicare contractor will decide whether to cover those services and procedures called the fiscal intermediary. “Fiscal Intermediary means any qualified insurance company or other Person that has entered into an ongoing relationship with any Governmental Authority to make payments to payees under Medicare, Medicaid, or any other federal, state, or local public health care or medical assistance program pursuant to any of the Health Care Laws”

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