When submitting professional claims to Medicare part B, there are some things that Medicare requires that differ from other insurance carriers. If you do not follow these guidelines or rules, you will find that your claims will be rejected.

First of all, most Medicare carriers are requiring that claims be submitted electronically, even if Medicare is secondary. If you are not capable of submitting your claims electronically you can apply for a waiver. An office with less than 10 full time employees can obtain a waiver granting them permission to file on paper. The CMS requires you to obtain a waiver certificate "demonstrating extraordinary circumstances". If accepted by Medicare, they can then file claims on paper. If you do not qualify for the waiver then you must find a method to submit your claims electronically.

If your software is not capable of electronic billing, which in this day and age would be unusual, or if you just do not want to go thru the expense or trouble, you can get a free software from your Medicare carrier. The biggest problem with using the free software is that it many times is cumbersome to use, and it requires double entry of the claims. However, if you do not submit a lot of Medicare claims it can be a viable option.

Another little quirk with Medicare is that they require you to enter the word "none" in box 11 (or the equivalent of box 11 if submitting electronically) on the CMS 1500 form. We have had many providers over the years contact us because "Medicare won't pay!" when it was all just because they didn't have the "none" in box 11.

Whenever we train a new employee that is one of the things we try to drill into their head! "Don't forget the 'NONE'!" There is nothing more annoying to me than getting a rejection to find that the only problem is that 'none' was missing. We are working with a company who is building a rules engine to prevent problems like this from getting thru. The claims scrubber will alert you to the missing word before you submit the claims!

Then of course there are the modifiers required only by Medicare such as the AT modifier for chiropractors or the GP modifier for physical therapists. These modifiers are not used by any of the other carriers, but without them Medicare will not pay.

Another thing Medicare requires is referring dr name and NPI number for simple in office services such as EKG's. So if one of my doctors decides to do an EKG on one of his patients, I have to put HIS name and NPI number in as the referring doctor, even though he provided the service. Seems kind of ridiculous to submit a claim for Dr. Smith doing an EKG where Dr. Smith referred the patient to himself. But if I don't put it in, the EKG is denied.

Another Medicare quirk is that many Medicare carriers (maybe all) require that you do not put the NPI number in box 24J if you are filing a claim for an individual provider who bills using just their individual NPI number. When the NPI number is in 24J for an individual provider, the claims are rejected. However, if you are filing a claim for a group, the individual NPI # must be listed in 24J and the group NPI# must be listed in box 33A.

When a claim is denied by Medicare or any other carrier, it is important to identify why the claim, or service, was denied. If the denial on the eob is not clear, call to get an explanation. If you do not agree with the reason for the denial ask what the process for appealing the denial is. If the claim was denied for something simple that you can fix easily, make the correction and resubmit the claim. If you do not understand the denial even after getting an explanation from a customer service rep, you can always Google it, or post a question on a good medical billing forum. The important thing is to take care of the denial and not to ignore it.





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