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5 Keys to Following Medicare Reimbursement Rules

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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

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