Commonly Asked Medicare Q & A

As an outsourced medical billing company I get many questions regarding Medicare.  I will keep track of these questions and publish some of them periodically on my blog.  Below are answers to three commonly asked questions.

Do Medicare rules apply to patients who don’t have Medicare?

Medicare has rules called “conditions of participation” regarding facilities and home care agencies and these rules apply whether or not the patient has Medicare.  In order for the facility to maintain its Medicare provider status, it must meet the conditions of participation.  On the other hand, Medicare only stipulates that these rules only apply to Medicare patients and do not have any connection with other payers.  So if there is a patient that comes in for an office visit and they do not have Medicare or any other type of insurance and will be paying for the visit themselves, the provider does not have to accept Medicare’s rates and does not have to meet Medicare’s required documentation or disclosure requirements or Medicare’s performance measures.

What constitutes an “Initial Visit” for Medicare billing?

For example, if a patient comes into the office to receive results of a sleep study can this be billed as an initial visit?  An initial visit or a “new patient” visit is a face-to-face visit.  If you are going over and giving the results of the sleep study with the patient present and have given further instruction and have a treatment plan, this is an initial visit.  If the patient is not present when giving the results, then this is not a visit.  According to Medicare, a patient qualifies as a new patient when they have not been seen in over 3 years.  If the patient has not been seen for over 3 years, an initial visit can be billed.  If a patient visits the hospital, then one initial visit per patient per hospitalization is allowed.  All other visits while the patient is hospitalized are to be billed as subsequent visits.

Can more than one Nurse Practitioner bill a Medicare patient on the same day?

In some cases this is allowed.  For example, if there are two Nurse Practioners one being the primary care nurse that bills Medicare one diagnosis and the other Nurse Practioner being in a specialty practice bills for a different diagnoses on the same day.  Will the bills for these visits through two separate practices and two separate provider numbers be paid by Medicare?  Yes. According to Medicare rules, both claims would be paid.  The reason they will be both paid is due to their being two different diagnoses on each claim and the bills are being generated by two separate providers.  However, when there are cases of two Nurse Practitioners who have billed for the same day with the same diagnosis, it is likely that one of these claims will be rejected by Medicare.  In this case, it is extremely important that the Nurse Practitioner has justification through their progress notes to back up their claim.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Billing and Collections During Hard Economic Times Part I

Insurance companies are more and more shrinking reimbursement to physicians.  Unfortunately this is out of the physicians control but there’s hope.   Physicians and medical insurance billers need to be more aggressive and in turn they will be more successful in collecting payment from insurance companies and patients that is owed to them.  There are two aspects of revenue being decreased.  First, claims are being denied by insurers and some claims are not resubmitted after a denial, or if they are resubmitted, they are past the allowable date.  Generally, about 7% to 15% of claims are denied by insurers. 

Second, because of these hard economic times, patients are simply not paying their bills.  A study showed that 40% to 50% of patient balances are not being paid.  This is sometimes due to high deductible health plans and the rise in people losing their jobs.

Most physicians have mastered their specialty but didn’t realize that they would have to become business owners and also would need to learn the billing part of their business. 

Physicians should compile a spreadsheet that shows each month’s accounts receivable compared to the prior months.  It should also list the date of submission of all claims and the number of denials each month.  The number of denied claims resubmitted and the time that it took to resubmit the denied claims.

Offices that employ an onsite biller can delegate this responsibility to this person; or even better using an outside billing service they should be able to provide this type of report for you.

 Start with denied claims

Some of the most common reasons a claim is denied is problems with eligibility and benefits verification.  This should be verified EVERY time a patient comes in the office, even if it was the day before.  Anything can change and it could mean losing out on revenue.  Some other reasons are miscoding, duplicate submissions, transposed or missing numbers and billing the secondary insurance plan instead of the primary plan.

Improve the way patients are checked in during the registration process.  It may take a little more time but the form that patients fill out when they are new or returning should be thoroughly gone over with the patient to verify everything is correct.  On the patient registration form at the top should be an expiration date of the form that should be         re-filled out after at least a year.  Changes happen in people’s lives everyday; divorce, new insurance, new job, change of address, change of phone number and all these things can affect your claim and could lead to a denial.

In the following article we will continue to discuss ways to collect and how to avoid denials from insurance companies.  Collecting from patients will be the next subject we discuss in detail.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

“Like” us on Facebook at