Medicare Reimbursement is the practice in which Medicare beneficiaries are not billed directly for services, but instead utilize Medicare to pay physicians or hospitals who offered the service. In some events, you may have to pay the bill up front, and file for reimbursement afterwards. This can be tricky, and there is a lot to take into consideration when filing for reimbursement. Here are a few basics can help keep healthcare providers in compliance with Medicare rules.
- Go directly to the source.
The Centers for Medicare & Medicaid Service (CMS) and its Medicare contractors publish detailed information related to most any question or concern. Assume that the answer is out there, you just have to find it. The sheer volume of information available can present its own challenges to answering a precise question but odds are that you will find what you need. When you do find the documentation, save it along with the original question as reference for any future inquires.
- Only seek documents or references from CMS.
Unsubstantiated advice is not a compliance plan. This type of advice usually comes in the form of free advice, be wary. Having said that, sometimes advice may be useful in the search for the source reference material.
- Avoid payment-based advice.
The question “Can I get paid for that?” is a loaded one. Medicare claim processing is built on the premise that providers know the rules. This is the most dangerous kind of advice. The ability to get paid is not equivalent to following the law. A quick search of “Medicare fraud arrest” will detail the practices of thousands of people that got paid.
- Don’t trust Medicare customer service staff.
The customer service staff at the Medicare carriers are line level staff that do not have extensive knowledge to answer your specific question. In fact, there is no person that could possess all of the information possible to respond to general incoming calls. Any advice you may receive from a customer service representative is a guess based on limited information at best.
- If all else fails, hire a consultant.
Hiring a consultant who can locate the definitive answer and provide documentation from CMS is the best place to turn when you hit a roadblock. Consultants come in many varieties and costs. Just remember that you are looking for the “gold standard,” which is CMS documentation.
When filing for reimbursement, it’s essential to stay informed and have confidence in your decisions. Always assume the answer is out there and never hesitate to seek outside assistance. Don’t rely solely on Medicare representatives for answers. Doing a little research beforehand may seem tedious but can save you time and money in the long run.
Popular media talks about “free” preventive exams or physicals offered through the Affordable Care Act (Hey reporters! They aren’t free). Millions dutifully head to their doctor each year to receive their preventive exam. But are these exams truly effective in preventing future health issues?
Did the ACA create a “wellness culture” across society as hoped with these preventive programs? Unfortunately not. It seems the ACA created more healthcare services that otherwise would not have been necessary or utilized. There may be isolated exceptions, but the U.S. healthcare system still focuses on sickness rather than wellness. Preventive care exams are mostly to detect sickness, not to promote wellness.
Annual visits may be described as preventive but seem to be merely annual physicals that create a record of basic measures and perhaps catch illness earlier. Sometimes the incentives for preventive or wellness exams are the sole reason for a patient to attend them. Many large employers offer bonuses, gift cards, and other rewards for completing a wellness exam.
The ACA disappointment is that wellness seems to be missing. Do we need to pay a doctor to tell us annually that we eat too much, drink too much, or smoke too much? Yes, many of us do. Maybe we need a doctor to translate the effects of habits into disease process, pain, and death to help us understand the importance. Instruction on how to change habits would be a powerful method to promote wellness.
We live in a time where a high percentage of U.S. medical care, disease processes, and healthcare costs are caused by lifestyle choices. Do preventive exams address lifestyle factors such as a taxing career, mental stress, family dynamics, and more? Does the ACA overall address these lifestyle choices? In most cases they do not and require extra effort on the part of the patient to address said issues.
Let’s face it, traditional medicine is not designed to promote good lifestyles. Medicine can, however, keep you living a long time despite your lifestyle. Many see medicine as the solution and forego any attempt at living a healthier life.
The cost of preventing future sickness will no doubt be less than those incurred once an illness or condition is diagnosed. We tend to think of costs in purely financial terms, but there are costs to our health if we do not live a healthy life. It can be more expensive to join a gym, eat more natural foods, and live an active life, but those costs are preferential to the result of not engaging in these practices. It’s time we start focusing on wellness from the start and commit to good habits before a physician or medical professional advises so.