Welcome to TIM Talks: Business Acumen

“Medicare Billing and Dual Eligible Populations”

July 19th, 2016
Medicare Billing 

and Dual Eligible 

Populations

Timothy P. McNeill, RN, MPH
Medicare Provider Application Process

Implications of being a Medicare Provider

 Billing for Dual Eligible Beneficiaries 

Q & A

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What Does Medicare Cover?

• Part A: Medicare Part A covers inpatient hospital care, 

skilled nursing facility care, home health services, and 

hospice.

• Part B: Medicare Part B covers physician services, 

office visits, screenings, therapies, preventive services, 

outpatient services, emergency care, ambulance 

services, medical supplies and durable medical 

equipment.

• Part C: Medicare Part C is the private health insurance 

option for Medicare beneficiaries. Medicare Part C is 

often referred to as Medicare Advantage. 

• Part D: Medicare Part D is the prescription drug 

 benefit option.
What are the types of Medicare Providers?

• Organizations can become a Medicare Provider as long as 

they can provide at least one (1) Medicare service

– Exception: The one service cannot exclusively be Diabetes SelfManagement Training (DSMT)

• Medical Nutrition Therapy is an acceptable service to 

obtain a Medicare provider number

– The Organization will submit as a “Group Practice”

– The dietitian will be the provider linked to the Group Practice 

application

– Additional services can be provided based on additional provider 

types obtained (e.g. LCSW- Therapy, Nurse Practitioner)
What is the Application Process?

• Medicare provider applications are submitted to your 

MAC

• MAC: Medicare Administrative Contractor

– Process Medicare FFS claims 

– Enroll providers in the Medicare FFS program

– Review medical records

– Respond to provider inquiries

– Find your MAC at this address:

https://www.cms.gov/Medicare/Medicare-Contracting/MedicareAdministrative-Contractors/Downloads/AB-MAC-Jurisdiction-MapDec-2015.pdf
MAC Map

A/B Jurisdiction Map as of December 2015
Application Forms

• 855B – https://www.cms.gov/Medicare/CMS-Forms/CMSForms/Downloads/cms855b.pdf

• 855i - https://www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms855i.pdf

• 855R - https://www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms855r.pdf

• 588 - https://www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms588.pdf
Form Completion Process

• Complete forms simultaneously

• The Primary application is the 855B

• Submit completed application forms to the MAC using 

the PECOS system

• PECOS

– Internet-Based Provider Enrollment, Chain and Ownership 

System

– Faster than paper-based enrollment

– Available at: https://pecos.cms.hhs.gov/pecos/login.do
Ownership Interest

• All Medicare Provider applicants must disclose each 

member that has control of the organization

– Board Members for a Non-Profit

– Each person must sign a form stating that they have No 

Adverse Legal Action History that prevents their 

participation

– Liability is shared when fraud occurs
Additional Forms

• CMS Form 588: Authorization for Electronic Funds 

Transfer

• CMS Form 855i: Registers the provider with Medicare

• CMS Form 855R: Authorizes CMS to pay the 

organization for professional services rendered by the 

independent provider 
Medicare Part B Deductible 

• CMS 2015 Medicare Cost estimates

– Part A premium

• Most people don’t pay a monthly premium for Part A

– Part B premium

• Most people pay $104.90 each month

• Total ($104.90 x 12 mo) = $1,258.80/year

– Part B deductible

• $147.00 per year (for most beneficiaries)

– Part C and Part D premiums

• Amount varies by plan
Medigap Market

• Medicare Part B beneficiaries can purchase a 

Medigap or supplemental policy to cover the 20% 

coinsurance requirements

• A Medigap policy defined

• Health insurance sold by private insurance companies to 

fill gaps in Original Medicare coverage

• Coinsurance, copayments, deductibles

• If a beneficiary elects Medicare Advantage, they cannot 

be sold or use a Medigap policy

• Beneficiaries with Medicaid (Duals) generally cannot 

buy a Medigap policy
Medicare Number and Liability

• Submitting Medicare claims for services opens an 

organization to legal and financial liability

• You must obtain proper insurance coverage to protect 

against potential liability

– Professional liability insurance

– Cyber Insurance

• Liability coverage does not protect against fraud
CBO Example #1

• A Northeast AAA successfully completed DSMT 

accreditation along with a Medicare Provider Partner

• After their experience with CCTP they discovered that 

there was an unmet need for counseling for persons with 

chronic depression

• The AAA obtained a Medicare provider number and now 

they provide DSMT/MNT and counseling services for 

Medicare beneficiaries

– All three services are billed to Medicare
CBO Example #2

• One of the AAAs in a Southern State obtained DSMT 

Accreditation 

• They partnered with a Home Health agency as the billing 

partner

• The partnership became contentious and they parted ways

• The AAA obtained their own Medicare provider number 

and now they are seeking reimbursement directly for 

DSMT
Common Billing Terms

• Explanation of Benefits (EOB) – When a claim for medical 

insurance benefits is processed, Medicare sends a notice called an 

EOB to the individual. 

• Current Procedural Terminology (CPT) - CPT codes are the 

copyrighted material of the American Medical Association (AMA).

• G Codes: Special set of codes that are not described in normal CPB 

coding. An example of commonly used G codes are the diabetes 

self-management training (DSMT) codes.
Medicare Providers and Alternative Payment 

Models

• The Medicare Access and CHIP Reauthorization Act 

(MACRA) will expand provider participation in 

Alternative Payment Models (APMs)

• Two primary APMs include the following:

– Accountable Care Organizations

– Bundled Payment

• APMs provide an opportunity for Gainsharing and shared 

savings participation

• Gainsharing requires having a Medicare provider 

number to participate
Dual Eligible Beneficiaries

• Duals are persons with both Medicare & Medicaid

• Commonly referred to as a Dual Eligible or a Medi-Medi

• Medicaid is required to pay the co-insurance and deductibles 

for Duals

• Provider must first bill Medicare and then bill Medicaid for the 

second portion
Coverage for Dual Eligible Beneficiaries

• Participate in Medicare VBP program models

• Duals hold the greatest financial risk in a VBP contract

• Duals Eligible beneficiaries have Medicaid as the 

Medigap coverage policy

• Medicaid must cover the co-insurance, even if the service 

is not a current Medicaid covered benefit in that particular 

State.
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