Home » Medicare and Medicare Advantage Medical Billing Dos and Don’ts

Medicare and Medicare Advantage Medical Billing Dos and Don’ts

by John

Unlike traditional insurance claims, billers have to be extremely cautious while submitting claims to Medicare – one of the high-volume payers based in the United States. Medical billing specialists must carefully process their claims and submit ‘clean’ bills to avoid denials. Fortunately, Sybrid MDSybrid MD has aced in dealing with Medicare and Medicaid health coverage programs.

With the help of Sybrid MD, we have noted some dos and don’ts that a biller should know while processing a Medicare or Medicaid Advantage claim. But let’s first have a look at what these programs aim for.

About Medicare Program:

Medicare is a health insurance program offered by the US federal government. The program aims to aid those 65 or older, youngsters with disabilities, and patients with last-stage Renal disease. To learn more about Medicare insurance and your own personal options, it’s recommended to consult with a Medicare insurance agent licensed in your state. Search the online directory of licensed Medicare insurance agents to find an agent near you! The program is divided into three parts:

  1. Medicare Hospital Insurance

Part A of the program covers inpatient care at a nursing facility, hospital, hospice care and home healthcare.

  • Medicare Medical Insurance:

Part B mainly deals with physician’s services, outpatient care, preventive services and medical supplies.

  • Medicare Prescription Drug Coverage:

Like its name implies, this one covers the costs of prescription drugs, including recommended vaccines and shots.

What is Medicare Advantage?

Once you get yourself enrolled in a Medicare program, it offers you two ways to get your Medicare coverage; Original Medicare and Medicare Advantage.

While the Original Medicare plan covers a big chunk, you must pay at least 20% of the bill for the rendered services. On the other hand, Medicare Advantage offers an alternative to the Original plan, partnering with private companies. It covers additional healthcare services that the Original Medicare plan does not. Apart from the services offered by the original plan, it covers hearing, vision and dental.

Medicare billing Do’s and Don’ts:

  1. Don’t confuse Medicare Advantage with Medicare:

Billers often confuse Medicare with the Medicare Advantage program. However, they both are two different plans and are processed differently. Medicare Advantage plan covers all traditional services, including Part A, B and sometimes Part D (prescription drugs), while the traditional one only offers Part A and B.

  • Verify Patient’s insurance plan coverage and eligibility:

To prevent costly claim denials and rejections, it is a biller’s job to verify a patient’s insurance coverage and eligibility prior to their visit. Some patients may not even realize that they are registered in a Medicare Advantage plan and only provide you with their Medicare Beneficiary Identifier (MBI) card. Therefore, benefits and eligibility verification should be a biller’s first priority in the patient’s intake process.

  • Use MBI when billing a Medicare patient:

It is recommended that healthcare providers use the Medicare Beneficiary Identification card while billing Medicare, irrespective of the date of the services. Failure to use those alphanumeric digits will result in claim rejection and eligibility transactions by the CMS.

Typically the MBI contains 0-9 numbers and UPPERCASE letters. Always remember that there is no Z, I, L, O, S and B in the MBI card. Also, make sure you do not use spaces and hyphens when entering MBI on the claim. Incorrect code will result in claim rejection.

  • Verify if the Part B Medicare deductible has been done:

Medicare beneficiaries must pay the Part B deductible each calendar year before the organization pays its part. As a billing specialist, it’s your responsibility to verify that the beneficiaries have met the deductible. In 2022, the deductible amount was increased to $233.

  • Bill Medicare Advantage plan under CMS guidelines:

Unlike traditional Medicare plans, Medicare Advantage plans are all-inclusive. However, they must follow CMS rules pertaining to coding, billing, claim submissions and reimbursement for successful billing completion.

  • Verify additional benefits to prevent billing rejection:

Some Medicare Advantage plans cover additional benefits like hearing, vision and dental services. Before processing a claim, verify the effective date of the policy as well as the insurance data. Acquire authorization beforehand for particular services, if required. Also, don’t forget to confirm the care receiver’s out-of-pocket expense.

  • Be careful with NCS and LCD Guidelines:

Medicare Advantage plan complies with Medicare policies and guidelines and must have access to necessary documents if needed. While coding eye care claims, ensure you are thorough with CMS National Coverage Determinations (NCD), Local Coverage Determination (LCD) and Medicare Administrative Contractors (MAC).

  • Use ABN where needed:

A biller must know when to use An Advance Beneficiary Notice of Noncoverage (ABN) document that aims to inform the patient they may be liable to pay for the rendered services if their payer denies the claim.

For instance, if you are unsure whether a specific service is covered under the Medicare Advantage plan, in that case, you must get an ABN document to the patient before administering the procedure. Failure to do so will result in revenue loss from the non-covered services.

  • Accurately Document E/M Patient visit records:

E/M code is applied when a patient is being provided with services involving health evaluation and management. A biller must keep E/M service records accurately with clear reference and verification.

  1. Examine Common claims and coding denials reasons:

The majority of claim rejections are due to coding and administrative errors. For instance, the required modifier is not mentioned, or the code doesn’t match the modifier that was used. While these errors can be fixed, it is best to prevent them in the first place. Once these errors are detected and fixed, they can be resubmitted to the payer.


Medical billing and coding is an intricate job. No wonder it’s one of the high-paying jobs in the United States. If you are a billing specialist, make sure you know all the aforementioned dos and don’ts; otherwise, you will end up with dissatisfied patients and revenue loss.

Sybrid MD believes in prevention than fixes. Their expert coding and billing specialists are thoroughly trained to process claims and obtain reimbursements accurately and efficiently. If you wish to achieve customer satisfaction and boost revenue, these guidelines should be at your fingertips.

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