Impact of Medicare on Medical Billing
Medicare has had a significant impact on medical billing in several ways, which are considered to have a considerable effect on health care service provision. When Medicare receives a payment claim, the processing is undertaken by the Medicare Administrative Contractor (MAC). MAC has an essential role in ensuring that it evaluates each of the applications to determine whether they are genuine after which the payments are then processed depending on the outcome of the evaluation (Alley, Asomugha, Conway, & Sanghavi, 2016). The processing of the claims usually takes approximately 30 days before payments are made. When dealing with traditional Medicare, which is covered in Part A and B, the protocol for billing is usually similar to the protocol used by private health insurance and third-party payers. The idea is that the superbill will be created from the medical coder to determine the amounts paid for health services rendered.
However, billing for Part C and D often introduces a wide array of complications attributed to the nature of services that can be billed to Medicare. Part C is considered as a private insurance plan, which is paid by the federal government (partly) to support the care services provided; thus, meaning that billers are not expected to bill Medicare for any services offered to patients in this part (Jencks, Williams, & Coleman, 2009). On the other hand, Part D creates a provision that only providers, who have the license to the bill, are expected to bill Medicare focusing on vaccines or prescription drugs. If the provider does not have the license to bill Medicare for Part D, the patient will likely be assigned to different secondary insurance. That means that patients without secondary insurance will be expected to pay for these health services in cash; thus, making it a bit expensive for those that do not have private health insurance.
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When billing Medicare, billers are expected to use standard forms, which often bring to floor a few complications that are likely to impact on the billing process. An example can be seen from the fact that billers, who intend to bill for Part A, are required to make use of a UB-04 form, which is equally referred to as CMS-1450 (Rajaram et al., 2015). However, this is not the case for Part B, as the biller for Medicare is expected to use CMS-1500, which is a completely different form altogether. From this perspective, it is clear that the use of manual billing for Medicare often creates a high possibility of confusion concerning the forms that the billers are expected to use as part of the billing process depending on the claims.
Eligibility for Medicare and Medicaid Benefits
For one to be eligible for Medicare or Medicaid benefits, one is expected to meet some of the inclusion qualifications. It is important to note that the requirements have been divided into two main categories, which are 65 years or older and under 65 years. For persons over the age of 65 years, the first qualification is that they must be United States citizens or be a permanent resident living within the United States legally and for a period not less than five years. The second qualification is that an individual or his/her spouse must have worked for a period that qualifies them for social security or, where applicable, railroad retirement benefits (Kline, Bazell, Smith, Schumacher, Rajkumar, & Conway, 2015). It is essential to take note of the fact that one would be eligible for Medicare or Medicaid regardless of whether they are receiving the benefits currently.
If one is eligible for but has not received the benefits, the individual or his/her spouse must be a government employee or retiree, who, regardless of not receiving social security, paid into the Medicare or Medicaid taxes. In other words, this means that the individual or his/her spouse must have been paying Medicare or Medicaid payroll taxes to be considered as being eligible for the intended health benefits. When dealing with persons below the age of 65 years, the crucial first qualification that is regarded as is that an individual is entitled to social security disability benefits for a period that is not less than 24 months, which qualifies one immediately. The 24-month benefit period does not necessarily have to be consecutive, as some of the individuals are eligible for such benefits that are paid over a stretched period.
The second qualification for Medicare or Medicaid benefits is that one must be receiving a disability pension that is offered by the Railroad Retirement Board. However, for persons that are receiving the disability pension, they are expected to be evaluated further to determine whether they meet some of the set-out conditions. Thirdly, any person that is diagnosed with Lou Gehrig's disease, which is otherwise referred to as amyotrophic lateral sclerosis (ALS), qualifies for both Medicare and Medicaid benefits immediately (Altman & Frist, 2015). Lastly, one may also be eligible for the benefits if he or she suffers from permanent kidney failure that may require dialysis or transplant. In this qualification, the individual or his/her spouse must have paid social security taxes for a specific period, which is determined depending on the age of the person seeking eligibility.
The Affordable Care Act (ACA) and Medicare and Medicaid Benefits
The Affordable Care Act (ACA) has had significant impacts on Medicare and Medicaid recipients, which can be especially quantified concerning reducing health care costs and increasing the quality of services offered. The enactment of ACA created provision through which Medicare and Medicaid recipients would be able to be provided with free coverage with the focus being on preventive benefits (Lee et al., 2018). For example, Medicare and Medicaid recipients are provided with free medical screening for chronic conditions such as cancer, diabetes, and cardiovascular disease. ACA intended to create an avenue through which the focus would shift from curative to preventive care as a way of minimizing the cost margins associated with the provision of health care services.
Another fundamental impact that ACA had on Medicare and Medicaid recipients is that it sought to close the coverage gap concerning vaccines and prescription drugs, which were not covered by both insurance covers (Wang, Tsugawa, Figueroa, & Jha, 2016). Traditionally, Medicare and Medicaid did not cover vaccines and prescription drugs, which were covered by secondary insurance or, in cases where individuals do not have any other insurance, paid in cash. The challenge for a majority of the people was that it was hard for them to access such services taking into account that a significant number of people in the United States cannot afford private health insurance. In that view, the coverage expansion was seen as a critical approach seeking to enhance overall outcomes concerning creating a shift in health care service providers within the United States.
References
Alley, D. E., Asomugha, C. N., Conway, P. H., & Sanghavi, D. M. (2016). Accountable health communities—addressing social needs through Medicare and Medicaid. N Engl J Med , 374 (1), 8-11.
Altman, D., & Frist, W. H. (2015). Medicare and Medicaid at 50 years: perspectives of beneficiaries, health care professionals and institutions, and policymakers. Jama , 314 (4), 384-395.
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine , 360 (14), 1418-1428.
Kline, R. M., Bazell, C., Smith, E., Schumacher, H., Rajkumar, R., & Conway, P. H. (2015). Centers for Medicare and Medicaid Services: using an episode-based payment model to improve oncology care. Journal of oncology practice , 11 (2), 114-116.
Lee, Y., Mozaffarian, D., Huang, Y., Liu, J., Sy, S., Wilde, P. E., ... & Micha, R. (2018). Cost-effectiveness of financial incentives for improving diet through Medicare and Medicaid. Circulation , 137 (suppl_1), A037-A037.
Rajaram, R., Chung, J. W., Kinnier, C. V., Barnard, C., Mohanty, S., Pavey, E. S., ... & Bilimoria, K. Y. (2015). Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services hospital-acquired condition reduction program. Jama , 314 (4), 375-383.
Wang, D. E., Tsugawa, Y., Figueroa, J. F., & Jha, A. K. (2016). Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes. JAMA internal medicine , 176 (6), 848-850.
