Medicare Part B Billing - Differences and Coverage

Learn the basics of Medicare Part B billing (coverage, application) and the difference between regular and Part B billing and coding...

Very simply, Medicare is the federally-funded program that provides healthcare coverage for the disabled and elderly.

There are four types of Medicare:

  • Part A covers inpatient hospital care as well as skilled nursing facility care, hospice care, and home health care.
  • Part B covers physician services, outpatient care, and other medical services, which are not otherwise covered under part A Medicare.
  • Part C combines Parts A and B (and sometimes D), and is managed by private insurance companies as approved by Medicare.
  • Part D is a prescription drug coverage program which is also managed by private insurance companies as approved by Medicare.

Each of these parts provides a different type of coverage, with different limitations and different billing requirements.

Medicare Part B

Medicare logo

Medicare part B is the plan that you use to go see your doctor, whereas Medicare part A is the plan that you'd use if you were an inpatient in a hospital. The two are not interchangeable!

An important thing to understand about Medicare Part B billing is that each person must pay a premium each month, and pay a yearly deductible and copay. As such, Part B is a lot like regular commercial insurance plans.

But unlike regular commercial insurance plans, Part B Medicare coverage only includes two types of services:

  • Medically Necessary Services: These include services and supplies needed to treat your medical condition. To be covered, the service also has to be within the standards of medical practice. This means that holistic or naturopathic treatments wouldn't be covered.

  • Preventive Services: These include healthcare services that are necessary for preventing illness rather than treating it. Methods of early detection, such as diagnostic exams for cancer, are also considered preventive medicine.

What does Part B cover?

CMS, the Centers for Medicare and Medicaid Services, governs all parts of Medicare, including Part B. CMS holds a great amount of influence over the way insurance companies pay doctors, as well as the services that doctors provide. This is, in large part, because of Medicare Part B restrictions.

Every type of healthcare service eligible for reimbursement by Part B is subject to a great deal of rules, regulations, and guidelines.

These range from the rule that all medical procedures must meet the standards of currently accepted medical practice, to the way certain claims must be billed for special services.

In other words, if you're involved in Medicare Part B billing, you'll have to know the specific rules and regulations that you, as the biller or coder, must follow to make sure your office gets paid by Medicare.

Medicare Part B is the plan you use when you go to see your doctor

It's important to remember that even though Part B is somewhat like a commercial insurance plan, it's still not a 100% coverage plan. Some of the covered services are the following, only when they're considered medically necessary:

  • Laboratory and Pathology services such as blood tests and urinalyses
  • Preventive services that will help prevent, manage, or diagnose a medical condition
  • Glaucoma tests, once per year
  • Bone mass measurement, once every two years
  • Colorectal cancer screenings
  • Diabetic screenings
  • Diabetic supplies
  • Diabetic self-management training
  • Cardiovascular screenings

Other services are covered by Part B Medicare, as long as they're related to one of the conditions that are considered medically necessary by Medicare. These services include:

  • Home health services, only when they are medically necessary, and of limited duration
  • Chiropractic services, only if it is to correct spinal subluxation
  • Ambulance services, only if a different type of transportation would endanger the patient's health
  • Blood that you may receive during a covered part B service
  • Clinical trials, as long as they're performed to help diagnose, treat, or prevent and illness or disease
  • Ambulatory Surgery Center care, for approved services
  • Emergency room services
  • Eyeglasses, only once and with frames, after a standard cataract surgery

Other preventative services are also covered under Medicare Part B:

  • Preventive shots, including the flu shot during flu season, and three Hepatitis B shots, if you're considered at risk
  • Hearing exams
  • Mammograms
  • Dialysis
  • Pap tests and pelvic exams
  • Mental health care
  • Occupational therapy
  • Physical therapy
  • Prosthetic devices
  • Transplant services

Submitting Medicare Part B billing claims

After you've determined that your patient has active coverage and that the service will be covered, you'll have to bill the claim to insurance.

Like other commercial insurances, you should send Medicare Part B claims directly to Medicare for payment, with an expected turnaround of about 30 days.

Unlike typical commercial insurance, Medicare can pay either the provider or the patient, depending on the assignment. If your provider has accepted assignment by Medicare, it means that he or she has agreed to accept the Medicare allowed amount as full payment on Medicare claims.

If your provider doesn't accept the assignment of Medicare fees, then he or she will send the claim to Medicare, which pays the patient directly. The patient, in this case, is responsible for paying the entire claim off to the provider.

No matter what type of insurance a patient has, it's important to understand the limitations you may have because of their insurance coverage.

The same goes for Medicare Part B billing. But in this case keeping in mind the rules, regulations, and guidelines is especially relevant.

Because Medicare is a service provided for the elderly, disabled, and retired, the patients who are covered by Medicare will usually have limited financial resources.

Because of this, it's very important to make sure that your office bills and codes within all Part B guidelines and provides only approved Part B services.

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