Billing Follow Up Medicare

About the role

The Medicare Billing and Follow-up Representative is responsible for the compliant, accurate and timely billing and follow-up of all hospital Medicare and Medicare Advantage Patient Accounts.

Responsibilities

• Submit Medicare/Medicare Advantage plan claims both electronic and paper claims (UB-04 and 1500) to the appropriate government and non-government payers
• Submit shadow bill (Information only claims) to Medicare
• Understand how to resolve Medicare/Medicare MA billing edits and/or warnings and billing edits that are identified in the Patient Accounting Billing System
• Keep abreast of Medicare/Medicare MA government requirements and regulations
• Understand ABN’s and the requirements when and how to appropriately bill claims for resolution
• Experience and knowledge with working the Medicare Quarterly Credit balance report
• Knowledge and understanding regarding the processing of the In-Patient lifetime reserved notifications, rules and regulations
• Knowledge and understanding working MSP (Medicare Secondary Payer) files
• Knowledge and understanding billing TPL (Third Party Liability) claims and conditional billing
• Current knowledge of Medicare Transmittal, Change Requests and the ability to understand and interpret Monthly CMS News Updates
• Understands LCD (Local Coverage Determination) and NCD (National Coverage Determination) and how it relates to medical necessity
• Understanding of the CMS Publication: 100-4 (Medicare Claims Processing Manual)
• Ensures claim information is complete and accurate in order to maximize the clean claim rate resulting in claim resolution and payment for complex billing and payment issues
• Analyze information contained within the Patient Accounting and Billing system to make decisions on how to proceed with the billing of an account
• Processes rejections by correcting any billing error and resubmitting claims to government and non-government payers
• Place unbillable claims on hold and properly communicate to various Hospital departments the information needed to accurately bill
• Submit corrected claims in the event that the original claim information has changed for various reasons
• Perform the billing of complex scenarios such as interim, self-audit, combined, and split billing etc.
• Limit the number of unreleased claims by reviewing all imported claims and either billing or holding the claim for further review
• Meet Billing and Follow-up productivity and quality requirements as developed by Leadership
• Measured on high production levels, quality of work output, in compliance with established CRH's policy and standards
• Review patient financial records and/or claims prior to submission to ensure payer-specific requirements are met
• Keep abreast of payer-specific and government requirements and regulations
• Follow up on unprocessed or unpaid claims until a claims resolution is achieved
• Generate letters to insurance or patients as needed in order to resolve unpaid claim issues
• Works on and maintains spreadsheets by sorting/adding pertinent data
• Analyze information contained within the billing systems to make decisions on how to proceed with the account
• Work independently and has the ability to make decisions relative to individual work activities
• Identify comments in the billing systems by using initials and using approved abbreviations for universal understanding
• Create appropriate documentation, correspondence, emails, etc. and ensure that they are scanned to the proper account for accurate documentation
• Read, understand, and explain benefits from all payers to coworkers, physicians, and patients
• Develop relationships with customers/patients/co-workers in order to gather and process information or resolve issues in order to receive accurate reimbursement and optimize internal and external customer satisfaction
• Post accurate adjustments as appropriate per billing policies and procedures, payer explanation of benefits, and the management directive
• Maintain work procedures pertinent to the job assignment
• Accountable for individual work activities
• Resolve questions that arise regarding correct charging and/or other concerns regarding services provided
• Complete cross-training, as deemed necessary by management, to ensure efficient department operations
• Report potential or identified problems with systems, payers, and processes to the manager in a timely manner.

Requirements

• CRCS Certification and or College degree preferred in health care or business-related field or High school diploma is significant with years of patient revenue cycle/process experience in lieu of college degree
• Additional specialized training relevant to job responsibility
• 5 plus years in a hospital setting with extensive background in hospital billing and follow-up functions
• Must exhibit very strong and/or been engaged in analytical and compliance issues