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Does Medicare Disapprove of the Claims?

Does Medicare Disapprove of the Claims

Medicare deals with numerous applications of Medicare claim every year. We have a great client serving team who looks into our policyholders’ claim issues and billings. Dealing with policies and Medicare bills has made us learn a lot. The Medicare team has mastered themselves in handling the denied applications too. Medicare indeed rejects some claims. Medicare has some strict rules for billings. Furthermore, the client-serving teams are not acknowledged how to bill a specific service. This unawareness can result in the denial of any claims. So, does Medicare disapprove of the claims? Let’s find out!

Error in Coding Can Result in Application Denial:

Each Medicare service is tagged with Healthcare Common Procedure Coding System (HCPCS). If a client faces rejection in the claim application due to the coding issues, they are most welcome to visit Medicare and address their query.

“Welcome to Medicare” visit is a precautionary measure covering 100 % of a visit if the beneficiary has Part B. On verifying the code, if it gives the output of the covered wellness visit and not the normal checkup, then Medicare will not cover the 100 % visit, and you have to encounter unnecessary billings. If such a scenario comes face to face, this is known as procedural code.

Now comes the diagnostic code error. This error can also cause a denial of claims. There are some services and medical procedures Medicare covers only if the person has a certain diagnosis.

When the doctor’s staff carry out the procedures very efficiently and adequately but deliver wrong diagnosis coding information to Medicare, there is a high possibility that Medicare will deny your claims. The lack of mastery in handling the appropriate diagnostic codes is one of the prominent coding errors. At NewMedicare.com, client services teams handle these errors for our policyholders.

Unnecessary Medical Facilities Can Result in Claims Denial by Medicare.

Medicare is not responsible for covering those areas that Medicare does not consider medically necessary to treat that illness and provide facilities. To eliminate such scenarios, Medicare requires a doctor to specify the need for each service they facilitate their patients with. Contrastingly, if the doctor feels the necessity to treat the patient, they do that. But the Medicare does not accept this service offered to patients by the doctor because the doctor did not prove any need in the patient.

The doctors have known non-Medicare insurance, which includes blood work. So, when the doctors treat Medicare insurance patients, they assume that it will also cover the routine blood work. That’s not how it works. Medicare demands a strong reason why the patient is being given any kind of blood work. If the doctors fail to represent with definitive reason to Medicare, they will deny the claim.

If the blood work is done as a Welcome to Medicare visit, then Medicare will not cover this blood work. Sometimes doctors think this and perform blood work on the patient during the welcome to the Medicare visit.

You will have to pay 20% of the cost of the blood work. You can save yourself from this payment if you have the Medigap plan. There is a possibility that you will not be aware of this, but when you receive the bill in your mailbox, you will be amazed.

Suppose the service providers make statements such as they won’t cover a few medical insurance areas. In that case, they must hand over an Advanced Beneficiary Notice of Non-Coverage to the patient. An ABN clearly states that Medicare will not process any claim. Also, if Medicare denies paying the charges, the individual will pay for the uncovered expenses.

If the doctor gives you an ABN, it’s your choice to sign it or not. Signing the ABN means that you can avail of that service, but Medicare will not cover it. The providers are not allowed to offer ABN for such services that Medicare does not cover. This includes the cosmetic area.

Coordination on Benefits Issues Will Lead to Denial of Medicare Claims:

Medicare consists of the COB department. This department manages the issue regarding the claims when you have insurance through companies or your employer. This department keeps an eye on who pays primary and who pays secondary. Specifically, if someone is working in a great organization, they will pay primary, and Medicare will pay secondary. Claims will adjust accordingly.

When the employer makes amendments in the coverage of medical insurance, he must inform Medicare. When Medicare gets to know about this update, they also make changes in their database, indicating that they are now the primary payers. However, a few times, the employer fails to make this change and inform Medicare.

Medicare Denies Claims for Non-Covered Services:

There are services like dental services, hearing solution services, and eyesight services that Medicare does not cover. Medicare will not cover these services unless there is a dire need for a patient to go for these services. For instance, if a patient is about to go for an organ transplant, Medicare will provide coverage there.

Medicare rarely provides coverage to these services. You will need to plan to get the services of a routine dental checkup, hearing solutions, and visionary solution. We at NewMedicare offer a DVH plan which covers these services.

Denied Claims Are a Serious Issue:

Claims deny process can be a hectic one. Instead of indulging yourself in this issue, you can leave this problem to our client service team. We at NewMedicare will go through and find out why there was a rejection in your claim. Our client service team will go through all the necessary procedures to resubmit the claim to make it acceptable.

We don’t charge our customers for these services and provide them with the finest output.

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