Verification of Medicare Replacement Plan Benefits Could Boost Your Revenue
More than 34% of people with Medicare are also enrolled in a Medicare replacement plan. Each of these plans works differently in what is covered, what documentation is needed and how claims are handled. If your practice is not getting the expected revenue from services billed to Medicare replacement plans, you are not alone. Sorting out the different plans and their details can be time-consuming, but an automated service can help. Automated checking of the patient’s coverage and claim status could prevent a backlog of payments and help your practice maintain a steady flow of income.
Medicare Isn’t What It Used to Be
Medicare was established in 1965 for people 65 years and older. The Medicare replacement plans were introduced in 1997 as Medicare Part C under the Balanced Budget Act. These plans have evolved quite a bit since they first came into being. Today’s Medicare isn’t what it was just a decade or two ago, and the Medicare replacement plans are also quite different. With so many replacement plans and provider networks, a practice might have trouble keeping track of all of the variations from one plan to the next.
Patients Have Multiple Coverage Plans
One of the biggest areas of confusion for practice is that patients often have multiple coverage plans. Sorting out which one to send the claim to might differ from one visit to the next. A patient might have employer-sponsored coverage, traditional Medicare and another HMO or PPO Medicare replacement plan. Some patients may have additional prescription coverage plans or MediGap plans. These plans have different coverage caps, their requirements for verification of benefits and varying provider networks.
A practice that treats the Medicare replacement plan the same as a traditional Medicare plan might find that their revenue is slower to come in due to missing information, ineligibility or failure to get pre-authorization for a specialist or a procedure. Some of the replacement plans even require prior authorization for medications that are not on the plan’s preferred drug list. You might not be sure of where to send the claim first, in which order to process the claims or how to handle a denial.
Differences in Medicare Replacement Plan Coverage
The Centers for Medicare and Medicaid regulate the coverage offered by different Medicare replacement plans. Almost every year, there are changes in the authorized benefits for every plan. In addition to the federal changes in benefits, the plans’ different providers may change their provider networks or drug formularies. Automated software makes it easier for your practice to stay abreast of these changes.
Before you order a test or recommend a particular specialist, you could use a benefits verification system to ensure that the procedure or specialist you recommend will be covered. This could reduce failure to follow up among your patients and lost revenue from denied claims or patients who cannot pay the out-of-pocket expenses.
How Software and Outsourcing the Verification of Benefits Works
When the Centers for Medicare and Medicaid change authorized benefits, the automated software is updated with those changes. We also update the verification software with any health maintenance organizations’ changes and preferred provider organizations. Using this modern technology, in conjunction with a denial management system and verification of the patient’s details and membership card, can eliminate a lot of the data entry errors, denied claims and slow speed of compensation.
What Your Practice Should Expect
Automated verification of benefits for Medicare replacement plans has a different impact on each practice that uses it. It is a good idea to set realistic expectations about how many medical billing errors the verification can prevent or how much faster the payments will roll into your account. There will always be a percentage of lost revenue no matter what type of billing system you choose for your practice, but you can minimize this number with the right system.
One action you could take is to compare the revenue you bring in from Medicare replacement plans to the local or regional averages that practices similar to yours bring in from the same plans. Although the distribution or types of Medicare replacement plans might vary from one practice to the next, and the services the patients need will also differ, making this comparison can still give you an idea of where your practice is on the spectrum.
Keep in mind that some specialties and locations have more Medicare replacement plan revenue than others. For example, 66% of Medicare enrollees in Miami-Dade County in Florida have a Medicare replacement plan, but only 10% of the Medicare enrollees in Monroe County have one. You may have to look within your city or even your ZIP code if your practice is in an urban area.
The rationale for Verifying Benefits of People With Medicare Replacement Plans
You may be curious about whether or not it is worth outsourcing the verification of benefits involving Medicare replacement plans. It might seem like one more system to figure out and one more vendor to pay on the surface. It might also seem like outsourcing the verification of benefits for patients with Medicare replacement plans just adds more complexity to your already-busy practice.
It is essential to know that the verification of Medicare replacement plan benefits is unlikely to impact anything that you or your administrative team does daily. Nearly all of the work and investigation is handled by automated, cloud-based software and off-site agents.
It is a good idea to look at your practice’s revenue before making any big business decisions. Review how much of your billing is paid for by Medicare replacement plans. Then, examine how many of those claims get sent back to your practice for reprocessing. Take a look at how many claims get denied. You may also want to look at how much extra time it takes to get the payments your practice is owed when the billing process starts out with an error.
You might find that your practice only has a few mismatches when billing a Medicare replacement plan for a service that it turns out not to cover. On the other hand, you might discover that improper verification of benefits for Medicare replacement plan holders is costing you a considerable amount of money and slowing down your cash flow. The low commission that your practice would pay for automatic verification could end up being a small amount of the revenue you can recover.
It is worth checking the numbers to see if your practice could benefit from an automated verification of benefits service. The all-in-one billing service provided by MedEffect could help your practice by pulling in the Medicare replacement plan payments in less time. We offer a free analysis of your practice’s data to show you which type of service plan is best suited to your situation and which one offers the best way to increase medical practice revenue.