A Rural Health Clinic's Guide to Medicare Advantage Billing

The Rural Health Clinic (RHC) program aims to provide access to primary care services for patients living in rural areas. RHCs might be nonprofit, public, or for-profit hospitals. They must use a team approach to provide services, with physicians collaborating with non-physician professionals such as physician assistants (PA), nurse practitioners (NP), and certified nurse midwives (CNM). The primary benefit of RHC classification is increased reimbursement rates for Medicare and Medicaid services. Is your email clogged with Medicare Advantage claim denials and rejections? It is time-consuming and stressful to investigate unpaid or refused rural health clinic claims. Let's go over a complete guide to Medicare Advantage Billing to help your clinic manage healthy cash flow and reduce out-of-control accounts receivable (AR).

• Verify the Patient’s Insurance Benefits and Check Eligibility

To prevent costly delays in claim rejections and denials, it is critical to verify each patient's insurance plan information prior to their visit. Some patients may be unaware that they are enrolled in a Medicare Advantage plan and will simply provide you with their Medicare Beneficiary Identifier (MBI) card. As a result, verifying eligibility and benefits is a vital first step in the patient intake process.

By establishing eligibility ahead of time, your rural health clinic can ensure that claims are issued to the relevant payer immediately following the patient's visit. You may even discover that the patient has additional vision coverage via other managed vision care (MVC) plans that they were not aware of. A rapid eligibility check can save time as Medicare keeps a record of reported "crossover plans," such as supplemental coverage or vision insurance plans.

• Follow CMS Rules When Billing Medicare Advantage Plans

Medicare Advantage plans are an "all-in-one" option to traditional Medicare plans offered by private insurers. All Medicare Advantage plans are approved by Medicare and must adhere to CMS guidelines for billing and coding, claim submission, and reimbursement.

Over 28 million Medicare beneficiaries will be enrolled in Medicare Advantage plans (also known as MA, Medicare Part C, or Medicare replacement) by 2022. Beneficiaries enrolling in Medicare Advantage programmes have more than doubled since 2007.  In 2022, there will be 3,834 Medicare Advantage plans available across the country, the most in more than a decade.

• Know When to Use an Advance Beneficiary Notice of Noncoverage

An Advance Beneficiary Notice of Noncoverage (ABN) is a letter of informed consent that directs the patient that if their insurance carrier denies the claim, they may be financially liable for the costs.

Assume you anticipate that Medicare Advantage will not fund a particular service. In that situation, you must obtain an Advance Beneficiary Notice of Noncoverage (ABN) before performing the indicated procedure or presenting the patient with the specified service. Failure to get a signed ABN form before performing the treatment or giving the service may result in the inability to bill the patient and receive payment for non-covered services.

• Confirm the Medicare Part B Annual Deductible Has Been Met

Medicare beneficiaries must fulfil their Medicare Part B yearly deductible each calendar year before Medicare will issue a payment. The annual deductible for all Medicare Part B users falls from $233 in 2022 to $226 in 2023. Non-covered expenses will not be deducted from your deductible.

CMS recommends that if you "accept assignment" for Medicare Part B, you do not collect the deductible from a patient until you have received the Medicare Part B payment or confirmed the deductible has been reached for the year. Why? It's more difficult to ascertain if a patient has met their deductible if you meet them early in the year. Consider scheduling your Medicare patients later in the year, after they have reached their deductible.

On the claim form, make a note of the coinsurance payment you collected for the covered service. Over-collection may be considered programme abuse by CMS, and it may result in a portion of the provider's cheque being sent to the beneficiary on assigned claims.

Alternatively, if Medicare Part B deems that you have been overpaid, the Medicare Administrative Contractor (MAC) will issue you a demand letter outlining the reimbursement request.

Experience Positive Cash Flow with Outsourcing

It's aggravating to look into rejected and refused claims. You and your in-house team can spend hours each week analysing unpaid claims and EOBs to determine the corrective and reprocessing processes for rejected and denied claims. Large ageing buckets cause disruption and reduce cash flow.

As a result, we recommend comprehensive proactive  rural health clinic billing, patient eligibility and benefits verification, and other revenue cycle management systems. 24/7 Medical Billing Services is ready to help you get paid faster and increase your practice's financial health.

See also: Rural Health Clinic (RHC) Billing And Reimbursement