cjhalk@yahoo.com
Guru
Good morning,
If we as coders find claims unbillable for whatever reason, we send back to the provider if we can for correction, clarification, signatures, whatever. If the provider never responds or refuses to make corrections, we send the claim to Medicare or to the patient.
As I understand it, we are required to send billing to Medicare if services are rendered:
(https://www.silvermanbain.com/avoid...viders who opt out of,and lasts for two years and https://www.medicareinteractive.org...ating-non-participating-and-opt-out-providers)
The Mandatory Claim Submission Rule
Federal law (42 U.S.C. § 1395u(b)(3)(B)) requires that any provider who is enrolled in Medicare (both participating or non-participating) must submit a claim to Medicare for any covered service furnished to a beneficiary. Providers may not simply give the patient a bill and ask them to submit it to Medicare. This rule is designed to protect patients from excessive charges and ensure consistent reimbursement rules are followed. The only lawful exception to this rule is when the provider has formally opted out of Medicare.
If we can't get the claim into a billable status, and we do not send the claim to Medicare, is this against this rule (or another rule) and could a hospital get into trouble for not sending a claim to Medicare? Or does this rule only apply to the example the link gives. You can't bill the patient or ask the patient to submit a bill. Past that, Medicare won't care if a claim is submitted or not.
To me, this seems pretty clear we are required to submit, but I am sure my facility is not the only one out there that has providers that won't clean up their documentation and make clarification. What do you all do with those claims? We don't bill or send to patient, they just sit there.
If we as coders find claims unbillable for whatever reason, we send back to the provider if we can for correction, clarification, signatures, whatever. If the provider never responds or refuses to make corrections, we send the claim to Medicare or to the patient.
As I understand it, we are required to send billing to Medicare if services are rendered:
(https://www.silvermanbain.com/avoid...viders who opt out of,and lasts for two years and https://www.medicareinteractive.org...ating-non-participating-and-opt-out-providers)
The Mandatory Claim Submission Rule
Federal law (42 U.S.C. § 1395u(b)(3)(B)) requires that any provider who is enrolled in Medicare (both participating or non-participating) must submit a claim to Medicare for any covered service furnished to a beneficiary. Providers may not simply give the patient a bill and ask them to submit it to Medicare. This rule is designed to protect patients from excessive charges and ensure consistent reimbursement rules are followed. The only lawful exception to this rule is when the provider has formally opted out of Medicare.
If we can't get the claim into a billable status, and we do not send the claim to Medicare, is this against this rule (or another rule) and could a hospital get into trouble for not sending a claim to Medicare? Or does this rule only apply to the example the link gives. You can't bill the patient or ask the patient to submit a bill. Past that, Medicare won't care if a claim is submitted or not.
To me, this seems pretty clear we are required to submit, but I am sure my facility is not the only one out there that has providers that won't clean up their documentation and make clarification. What do you all do with those claims? We don't bill or send to patient, they just sit there.