Are Your Medicare Collections and Revenue at Danger?

You might be unaware of the risk that your Medicare collections and Revenue could be at Danger. The loyal staff has mentioned that a recurring trend during analysis of customers’ Accounts Receivable. The claims being refused by Medicare for benefit non-coverage during the research of Medicare Part A or Medicare Part B Balances because of a patient being enrolled in a Managed Care/HMO/PPO plan that has replaced the Medicare Part A or Part B Benefits or vice-a-versa.

The matter of concern is that how can you stop this from happening in your facility and be certain that the suitable payer is being recognized and billed in a timely way?
​
The answer involves using a very basic and simple procedure including Medicare Eligibility and the Common Working File. We suggest that the Business Office Staff or an assigned staff member complete a Medicare Eligibility Benefit check, referred as the HIQA/MECCA check, utilizing the Medicare Direct Data Entry (DDE) System, to verify a resident’s present Medicare Eligibility status.  At a minimum the HIQA/MECCA check should be implemented for each of the following cases: 

---

• To evaluate the prospective residents Medicare or Managed Care/HMO/PPO Eligibility upon or before the admission.
• After having a 3 day/night qualifying stay in a hospital setting upon or before the readmission to the facility
• Whenever the Physician, Therapist or Clinical Team check a resident should start getting Part B Therapy Services
• During the monthly time on either the last day or 1st day of the month for entire present month residents getting Medicare Part A or Managed Care/HMO/PPO Benefit Services.

It is usual practice for the insurance agencies in today’s world who give these – Medicare Replacement policies to inundate the public with information extolling the advantages of enrolling in their policies vs. Medicare.

Provided these practices and information, it’s not unusual for spouses or family members to enroll, alter the policies or disenroll a resident from a policy during any provided month and forget to tell the Business Office that they’ve done so. The common and the mere way the facility finds this has happened is when a claim is denied for non-coverage.
If this change in benefit coverage isn’t founded in a timely manner it becomes much complex to get the claim paid. Several policies have restrictive billing time limit instructions and/or need a prior authorization.

Point to Note: Enrollment/disenrollment changes don’t become active until the first of the following month.

By using the obtained data, the Business Office Manager/Staff will take the suitable actions to make sure that census depicts the authentic payer and any required prior authorizations are got. They can then notify the suitable facility staff so that nursing notes, physician orders and therapy received are documented rightly and MDS assessments are completed on time.