10 Medicare and Medicare Advantage Medical Billing Dos and Don'ts

This blog was updated on November 7, 2022.

Is your inbox full of Medicare and Medicare Advantage claim rejections and denials? Researching unpaid or denied eye care claims is frustrating and time-consuming.

To guide your eye care practice toward managing healthier cash flow and reducing out-of-control accounts receivable (AR), let's review 10 common medical billing dos and don'ts.

1. Don’t Confuse Medicare Advantage Plans with Medicare.

If a patient has a Medicare Advantage plan, do not bill traditional Medicare. Medicare Advantage plans are not supplemental plans, and they must cover all traditional Medicare services, including Part A (hospital insurance) and Part B (medical insurance) coverage. Most Medicare Advantage plans cover Part D coverage (prescription drugs).

2. Verify the Patient’s Insurance Benefits and Check Eligibility.

It’s important to verify every patient’s insurance plan information before their visit to avoid costly delays in claim rejections and denials. Some patients might not even realize they are enrolled in a Medicare Advantage plan and may only give you their Medicare Beneficiary Identifier (MBI) card.

That’s why having eligibility and benefits verification is a critical first step in the patient intake process. By checking eligibility in advance, your office can ensure claims are filed to the correct payer right after the patient’s visit.

You might even find the patient has additional vision coverage through another managed vision care (MVC) plan they weren’t even aware they had. Medicare keeps a record of reported “crossover plans,” including supplemental coverage or vision insurance plans, so a quick eligibility check can save time.

3. Use the Medicare Beneficiary Identifier When Billing Medicare.

Healthcare providers must use (effective January 1, 2020) the 11-character alphanumeric Medicare Beneficiary Identifier (MBI) when billing Medicare, regardless of the date of service.

Image Source: Centers for Medicare & Medicaid Services

Suppose you do not use the MBI when submitting Medicare claims. The Centers for Medicare and Medicaid Services (CMS) will reject all eligibility transactions and claims with the old Social Security Number (SSN)-based Health Insurance Claim Numbers (HICN). However, there are a few exceptions for Medicare plans and Fee-for-Service claims.

The MBI uses numbers 0–9 and all UPPERCASE letters. There is never a letter B, I, L, O, S, or Z in the MBI. Do not include hyphens or spaces when you list the MBI on the claim form (see MBI format specifications). If you enter the MBI incorrectly, Medicare will deny your claim.

Always check your patient’s Medicare card and verify that the patient's name and address are correct. If your information on file differs from the Medicare address you get on electronic eligibility transactions, ask your patient to contact Social Security and update their Medicare records. Or, print out the CMS “Your Medicare Card” in English or Spanish.

Remember to replace the patient's SSN with the new MBI in the "Insured ID" field in your practice management software patient record so that the new ID will transfer to the e-claim and paper HCFA.

4. Confirm the Medicare Part B Annual Deductible Has Been Met.

Every calendar year, Medicare beneficiaries must meet their Medicare Part B annual deductible before Medicare makes a payment. In 2023, the annual deductible for all Medicare Part B beneficiaries is decreasing from $233 (2022) to $226. Non-covered expenses will not apply toward the deductible.

If you “accept assignment” for Medicare Part B, CMS recommends that you not collect the deductible from a patient until you receive the Medicare Part B payment, or you have confirmed the deductible has been met for the year. Reason? If you see a patient early in the year, it’s more challenging to know if they met their deductible. Consider scheduling your Medicare patients later in the year after their deductible has been met.

Note the coinsurance amount you collected for the covered service on the claim form. If you over-collect, CMS may consider this program abuse, and it can lead to part of the provider’s check being sent to the beneficiary on assigned claims.

Or, if Medicare Part B determines they overpaid you, the Medicare Administrative Contractor (MAC) will send you a demand letter that outlines the repayment request.

5. Follow CMS Rules When Billing Medicare Advantage Plans.

Medicare Advantage plans are an “all in one” alternative to traditional Medicare plans offered through private insurance companies. All Medicare Advantage plans are approved by Medicare and must follow CMS rules regarding coding, billing, submitting claims, and reimbursement.

6. Verify Vision Benefits to Avoid Billing Rejections and Denials.

Many Medicare Advantage plans provide extra coverage for vision-related items or services, such as preventive and routine vision coverage, eyeglasses, and intraocular lenses (IOLs) related services.

Verify that the insurance data is correct by confirming the effective and term dates of the insurance plan policy. Obtain prior authorization for specific services, if needed. Always confirm the patient’s out-of-pocket costs (co-payments, co-insurance, and deductibles).

Benefits vary from plan to plan, bill different out-of-pocket fees, and have rules for how you get paid for your services. Medicare Advantage payers usually pay providers per member per month (PMPM), partial or full-capitation, or a percent-of-revenue basis.

Related: Vision Plans Vs. Medical Insurance: When Should You Bill?

7. Be Diligent with LCD and NCD Guidelines.

Medicare Advantage plans follow Medicare guidelines, and providers must retain or have access to appropriate documentation if requested. To ensure you are coding your eye care claims correctly, be diligent with CMS Local Coverage Determinations (LCD), National Coverage Determinations (NCD), and Medicare Administrative Contractors (MAC). Sign up to receive payer listserv updates.

8. Know When to Use an Advance Beneficiary Notice of Noncoverage.

An Advance Beneficiary Notice of Noncoverage (ABN) is an informed consent document that informs the patient they may be financially liable for the costs should their insurance carrier deny the claim.

For example, suppose you suspect that Medicare or Medicare Advantage may not cover a procedure or service. In that case, you must obtain an Advance Beneficiary Notice of Noncoverage (ABN) before providing the specified procedure or service to the patient.

Failure to obtain a signed ABN form before providing the procedure or service could result in not being able to bill the patient and get paid for non-covered services.

See our Rules to Follow for Advance Beneficiary Notice of Noncoverage Guide for tips on when, why, and how you should use an ABN form.

9. Keep Accurate Records for Coding E/M Patient Visits.

Always keep accurate records documenting the specific Evaluation and Management (E/M) service (a category of CPT® codes used for billing) the patient received for the treatment —clearly reference, review, and verify.

Related: Medicare Billing Solutions for Cataract Post-Op Co-Management

10. Review Common Coding Denials and Adjustment Reasons.

A majority of claim denials are due to administrative errors. For example, the procedure code is inconsistent with the modifier you used or the required modifier is missing for the decision process (adjudication). Once you correct the errors, you can resubmit the claim to the insurance payer.

Experience Positive Cash Flow with Full-Service Optometric Billing Solutions

Researching rejected and denied claims is frustrating. You and your staff can spend hours each week analyzing unpaid claims and EOBs to determine the necessary steps to correct and reprocess rejected and denied claims. Huge aging buckets lead to chaos and less cash flow.

Complete proactive optometry billing, patient eligibility and benefits verification, and other revenue cycle management solutions are what we prescribe. Fast Pay Health is ready to help you get paid faster and grow the financial health of your practice. Request a free practice analysis today.

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