I am not sure how long you have been billing, but for someone who is relatively new to it, Medicare can be confusing. This is especially true for certain types of specialty billing. I have been billing for almost 25 years, so I don't find it confusing. It just takes time!
As for your questions:
1. Medicare puts out MLN Matters articles, and they are there to educate providers/staff/coders/billers on a variety of subjects. I have found that these are very helpful, as well as the NCD/LCD's that are put out by CMS and the local MAC carriers. Your local MAC will also offer webinars on specific subjects, and then put out transcripts of them. Judging by your username, do you bill for providers in Texas? If so, this is your MAC's website:
https://www.novitas-solutions.com/webcenter/portal/MedicareJHIf you haven't already, enroll for the Novitasphere Portal on that website, so you can access patient eligibility, which is one way you can determine if Medicare is primary or secondary for a patient, plus many other types of helpful information. You can also enroll with Availity, and then run Medicare patients through their eligibility function, and again it will tell you if Medicare is primary or not. You also always have the option of calling Novitas IVR to find out.
2. Generally speaking, if a patient is age 65 or over and retired, or under age 65 and disabled and receiving Medicare disability benefits, Medicare will be the primary insurance. There are exceptions to this, a few are if the Medicare beneficiary is over age 65 and still works, or has a spouse who does, or is disabled, but has a spouse who works, or a parent, in which case they could be covered under commercial insurance as primary, with Medicare being their secondary. This MLN article provides excellent information about how to determine if Medicare is primary or secondary:
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/msp_fact_sheet.pdfThere are times when a patient with Medicare as their primary has elected to go with a Medicare Advantage plan as opposed to having traditional Medicare. Often, they don't understand that the Medicare Advantage plan takes the place of traditional Medicare and any secondary/supplemental insurance they have had, so they will present their Medicare Advantage plan insurance card, and say it is primary, and then their traditional Medicare card (or sometimes their terminated secondary insurance card) and say that those are their insurances. In reality, all they have is the Medicare Advantage plan, and that is the only insurance that will be billed.
3. As to when you can actually send a statement to a Medicare patient(or any other patient, for that matter), that depends on a bunch of variables. Just because the PM system generates a statement, it does not mean that they are always accurate. I personally double-check each statement that is generated for all my clients patient's, every month, before I send them out. Some things to be aware of:
a. Does the patient have Medicaid as a secondary or tertiary insurance? If so, and the claim has processed through Medicaid, and there is a balance left over, you can only bill the patient for that balance depending on what TYPE of Medicaid coverage they have. If they are a QMB, you cannot bill the patient. There are several other types of coverage, and depending on what the patient has determines exactly what you can bill them for. Therefore, if a patient has Medicaid as a secondary or tertiary, you need to know what type of coverage they have, and it can change from month to month sometimes. The easiest way to do this is to register for the Medicaid portal in your state, and run their eligibility each time they are seen, to see what category they fall into. This article explains the different categories:
https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MedicareMedicaidEnrolleeCategories_08012018.pdfb. Were the services provided to the Medicare patient billed correctly/processed correctly? The ERA or EOB you receive from Medicare will state what the patient responsibility is for each claim. In most cases, after the claim has gone to Medicare, and they have paid their portion, and then the remaining insurances have processed the claim, any amount left over can then be billed to the patient (exception being Medicaid as stated above). Usually, the only times there will be anything for the patient to pay is if their secondary/tertiary insurance does not cover the Medicare deductible, or all or part of the 20% co-insurance due. Not all secondary/tertiary insurances pay for these things, depending upon the plan.
c. Did any of the services billed on the claim require an ABN be signed by the patient, and if so, was that done? You cannot bill a patient for services that needed an ABN signed, if the patient did not sign one. Here is an article that discusses this:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdfd. If a patient has not presented a secondary to be billed, there are times when they for whatever reason don't even know they have a secondary, believe it or not. Or, they DO have a secondary they present, but it is not on auto-crossover with Medicare. I always double-check my ERA's after they post for Medicare, and if there is a secondary listed that the claim has crossed over to, that the patient didn't tell us about, I add that to the PM system, so that the responsibility for the balance moves to that insurance next, and not to the patient. If there is no secondary listed on the ERA, but the patient has one with no auto-crossover, I then bill the secondary electronically or on paper.
e. If you see a statement for a claim that has denied in part or in whole, obviously you need to see why it has, based on the ERA remittance codes, and correct the issue, and resubmit. There are times when the denial will be for a CO-109, in which case you need to find out what the correct insurance is that should be billed, and rebill that insurance. If a patient doesn't respond to a request for the correct insurance, or you can't figure out what it is on your own, then a statement should be sent to the patient, because that will get their attention, and they will provide the correct info more often than not. Same thing when a COB is needed, and the patient doesn't respond to your request to call Medicare and get it done.
Hopefully, this information will help you. Let me know if you have any specific situations you need help with regarding all of this, and I or someone else will try to help you.
