Clinicians will contract with many commercial insurance providers during their careers, but the heavy hitters of reimbursements are government-backed insurance plans.
In this informative two-part series, Nitin Chhoda examines programs operated by the federal government and what practitioners should know about them.
Government-operated healthcare programs encompass Medicare, Medicaid, Workers’ Compensation, CHAMPUS and Tricare.
Of all the government-run insurance plans, Medicare is the largest and is comprised of four types of coverage, Part A, B, C and D.
Participation is mandatory for some portions and voluntary for others, leading to confusion for patients.
Congress dictates how Medicare claims are paid. Reimbursement requests must be submitted within a specified time frame and the agency prefers to pay providers via electronic fund transfer.
It’s critical for practitioners to verify which Medicare elements a client participates in before services are rendered.
Medicare Part A
The first part of Medicare coverage pays for inpatient care in hospitals, skilled nursing facilities, home healthcare and hospice, but an overnight stay in a hospital is no guarantee of payment. Clients must meet specific requirements for Medicare to pay for inpatient services.
Medicare Part B
The B portion of Medicare coverage is designed to pay for services, treatments and procedures that are medically necessary. Included are services by physicians, home health services, durable medical equipment and outpatient visits. Some preventative measures are covered, including vaccines.
Part B is optional, but those who don’t enroll according to government guidelines are penalized. Patients often believe they’re automatically enrolled when they retire and are dismayed to discover they have no coverage. Recipients also have an annual deductible and pay a 20 percent copay for services.
Medicare Part C
Part C, also known as Medicare Advantage, is an insurance replacement plan offered by private companies that have been Medicare approved. Part C is favored by individuals who prefer private insurance coverage. Depending on the provider, plans can require beneficiaries to pay out-of-pocket expenses, obtain referrals, and only see network providers.
Replacement plans can be used to cover Part A and B services, and some plans include medication and vision coverage. To avoid medical billing reimbursement difficulties and appeals, always verify the client’s coverage, restrictions and limitations prior to treatment, along with the plan’s fee schedule to determine if it differs from Medicare standards.
Medicare Part D
The Medicare prescription drug plan is Part D. While Part D coverage doesn’t typically cause a problem for medical professionals, a large number of Part D recipients mistakenly believe they’ve enrolled in a Medicare supplement policy. Practitioners may find they’re spending a significant amount of time explaining the difference to their patients.
Medicare Supplement Plans
Patients can enroll in a Medicare supplement program, also known as Medigap plans, to cover the costs that Medicare doesn’t pay. It provides a source of secondary coverage, but doesn’t include any non-approved Medicare expenses. Always verify secondary coverage prior to any patient encounter.
More than 50 million people age 65 or older and younger individuals with disabilities have some type of Medicare coverage.
It represents a large population of patients upon which practitioners can draw that are covered by a reliable payer.
Incentive payments may also be available for clinicians practicing in geographic areas with a demonstrated shortage of medical professionals.
