Physicians often expand their practices by accepting Medicare. This insurance program has a lower fee schedule than many other insurers, but it tends to pay promptly and consistently. However, the decision to accept Medicare isn't a one-time decision that never needs to be revisited once it's made. Instead, it requires regular examination to verify these claims are being processed properly, thus ensuring the practice is paid appropriately. In addition to maintaining its revenue stream, a practice that accepts Medicare must be able to pass regular Medicare audits.
A strategic approach is therefore essential for remaining profitable with Medicare. The best practices for handling Medicare claims include the following:
- Hiring a physician assistant (PA)
- Hiring a practice management vendor (PMV)
- Filing clean claims
- Developing a compliance plan
- Performing external audits
1. Hire a Physician Assistant (PA)
Hiring a physician’s assistant is one of the most effective methods of increasing the profit from Medicare. The cost-to-revenue ratio of treating Medicare patients is significantly lower for non-physician practitioners (NPP) than physicians, meaning it’s more profitable for NPPs to see these patients. This strategy lets a physician spend more of their time treating patients with insurance that pays more per relative value unit. An NPP thus allows a practice to treat Medicare patients with less use of the physician’s time.
An NPP can also help balance the practice’s schedule to maintain cash-flow equilibrium with Medicare. A physician should consider setting a strict maximum limit on the number of Medicare patients that the practice will see each day. A common strategy for meeting this goal is to set aside a specific number of daily time slots for each insurance type, including private insurance, Medicare and Medicaid.
2. Hire a Practice Management Vendor (PMV)
A practice management vendor (PMV) can benefit any medical practice, but this is especially true for those that accept Medicare patients. Medicare provides complete transparency on its edits for calculations such as Local Coverage Determinations, National Correct Coding Initiatives and National Coverage Determinations. Practices that handle Medicare claims will therefore be most successful when by hiring a PMV to obtain this information up front and validate claims prior to submission. Many PMVs also validate the codes and modifiers on claims.
This system of checks and balances is more difficult to implement for private insurance because these insurers still lack transparency on their edits. For example, private insurers often bury their payment policy deep in their website.
3. File Clean Claims
Filing clean claims the first time is essential for avoiding Medicare audits in the future. This practice is one of the “secrets” to making and keeping money in a Medicare practice, which can often be facilitated by hiring a certified medical coder. This step will also require a budget for ongoing training, as coding procedures change frequently. If a practice isn't large enough to justify hiring a full-time coder, it should outsource this function to a reputable medical billing company with Coding expertise.
4. Develop a Compliance Plan
A documented plan for complying with Medicare requirements will also help physicians handle these claims smoothly by reducing the risk of denials and re-coupments for Medicare claims. The United States Office of Inspector General (OIG) provides practices with guidance for small practices and individual physicians in activities such as implementing practice standards and performing internal monitoring.
Related Topic: Compliance is Best Left To Medical Billing Professionals
5. Perform External Audits
Many private and government insurers now expect physicians to hire external auditors as a result of the insurer's payback and self-disclosure policies. These auditors should be highly adept at identifying compliance and billing issues that could devastate a practice if left uncorrected.
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