Medical Billing to Medicare, Medicaid, and Tricare

Understanding the basics of health insurance plans and payers enable the medical office staff to effectively communicate with patients regarding their health insurance benefits and discuss patient account details with insurance company representatives. If you are interested in becoming a medical biller, here is a lesson on Medicare, Medicaid, Tricare, and other payers.


Understanding Medicare

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It is important to understand Medicare billing requirements which can be somewhat complex. Consider attending training events and opportunities. Providers must ensure that those responsible for preparing and submitting claims to Medicare are aware of proper submission guidelines and regulations.

There are four basic parts of the Medicare Program:

  1. Medicare Part A: Medicare Part A is the part of Medicare that most people don't have to pay for called hospital insurance. Medicare Part A is called the hospital insurance because it helps pay for the care a patient receives in a hospital inpatient setting, critical access hospital, skilled nursing facility (SNF), hospice and home health care.
  2. Medicare Part B: Medicare Part B is the part of Medicare called medical insurance. Part B covers most services not covered by Part A such as Physician Visits, Outpatient Treatments, Preventative Care, Medical Supplies, Ambulance Services, etc.
  3. Medicare Part C: Medicare Part C also known as Medicare+Choice but is referred to as Medicare Advantage Plans. Medicare Advantage Plans allow Medicare beneficiaries to enroll in a private health insurance or managed care plan of their choice. There is a wide variety of plans to choose from that offer services that are usually covered under traditional Medicare.
  4. Medicare Part D: This part of the Medicare program is the Prescription Drug Benefit. Drug coverage is only available through Medicare Advantage Plans.

Understanding Medicaid

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Medicaid is always the payer of last resort. This simply means that Medicaid always pays last where other health insurance plans are present. Recipients are required to keep Medicaid informed of any health insurance information.

Providers are also responsible for notifying Medicaid of third-party insurance they find out about as well as informing Medicaid of any third party payments they receive on behalf of the recipient.

Medicaid is state regulated, therefore, each state has its own billing requirements.  Billers must contact the Medicaid program in their own state to find out specific billing information.


Understanding Tricare

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TRICARE, a part of the Military Health System, is a health care program for active, retired and Guard/Reserve service members and their families. There are four different geographic regions that provide services to TRICARE beneficiaries:

  • North
  • South
  • West
  • Overseas

Understanding Other Payers

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Having a basic understanding of each type of insurance will minimize complications for filing claims and collecting payments. There are two major types of health insurance plans:

  • Indemnity Insurance: Indemnity insurance plans makes payments to the medical office based on the fee-for-service model.
  • Managed Care Plans: Manage care plans seek to manage the costs of health care for its members by coordinating and planning care with the network of physicians, specialists, and hospitals. There are four types of managed care plans:​
    • Health Maintenance Organizations (HMOs)
    • Preferred Provider Organizations (PPOs)
    •  Exclusive Provider Organizations (EPOs)
    • Point-of-Service (POS) Plans
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