Do Physicians Get Reimbursed for Medicare Part A?
Do physicians get reimbursed for Medicare Part A? The answer is a nuanced no. Physicians primarily bill Medicare Part B for their professional services, although they can be indirectly reimbursed for certain services delivered within a Part A-covered stay.
Understanding the Landscape: Medicare Parts A and B
Navigating the complexities of Medicare can be daunting. To understand whether physicians get reimbursed for Medicare Part A, it’s essential to first differentiate between Medicare Part A and Part B.
- Medicare Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
- Medicare Part B (Medical Insurance): Covers physician services, outpatient care, preventive services, and some home health care.
The key distinction lies in the type of service being provided, not necessarily where it is provided. While Part A covers institutional care, Part B covers the professional services provided by physicians, regardless of location.
The Role of Physicians in Part A Settings
Physicians play a crucial role in settings covered by Medicare Part A. For example, a hospitalist attending to a patient admitted to the hospital provides medical care essential for the patient’s recovery.
However, their professional fees are billed separately under Medicare Part B, even though the patient’s room and board, nursing care, and other facility-related costs are covered under Part A.
How Physicians Are Paid in Part A Contexts: Part B Billing
The primary method of reimbursement for physician services within a Part A setting is through Medicare Part B. Physicians submit claims directly to Medicare (or their Medicare Administrative Contractor, MAC) for their services using appropriate CPT (Current Procedural Terminology) codes. These codes represent specific procedures or services rendered. The amount Medicare pays is determined by the Medicare Physician Fee Schedule (MPFS).
- Fee-for-Service: Physicians are paid a set amount for each service they provide.
- Incident To: Certain services provided by non-physician practitioners (NPPs) like nurse practitioners or physician assistants can be billed under the physician’s name if certain requirements are met, such as direct supervision.
- Shared Visits: Physicians and NPPs can share patient visits in certain settings, and specific billing rules apply to determine which provider’s NPI (National Provider Identifier) is used on the claim.
Indirect Reimbursement: Physician Ownership & Agreements
While physicians generally don’t directly receive reimbursement for Medicare Part A, there are situations where they might indirectly benefit.
- Physician-Owned Hospitals: If a physician has an ownership stake in a hospital, they could indirectly benefit from the hospital’s Part A revenue. However, strict regulations exist to prevent self-referral and ensure quality of care (Stark Law and Anti-Kickback Statute).
- Contractual Agreements: Hospitals might contract with physician groups for specific services, such as emergency room coverage or hospitalist services. The hospital receives Part A reimbursement for the patient’s stay and then pays the physician group based on the contractual agreement. This does not mean the physician is being directly reimbursed by Medicare Part A.
Common Billing Mistakes in Part A Settings
Several common billing mistakes can arise when physicians treat patients in Part A settings, leading to claim denials or delays.
- Incorrect Place of Service (POS) Coding: Accurately reflecting the place of service is crucial. Failing to use the correct POS code can lead to claim denials. For instance, billing a service as “office visit” when it was performed in the hospital.
- Lack of Medical Necessity: Medicare requires all services to be medically necessary. Insufficient documentation to support the medical necessity of a service will result in denial.
- Duplication of Billing: Billing for services that are already included in the hospital’s bundled payment under Part A is prohibited. This includes certain types of diagnostic tests or procedures.
- Incorrect Modifier Usage: Certain modifiers are necessary when billing for services performed under specific circumstances (e.g., shared visits, reduced services). Incorrect or missing modifiers can lead to claim rejections.
The Role of Medicare Advantage Plans
Medicare Advantage (MA) plans (Part C) are private health plans that contract with Medicare to provide Part A and Part B benefits. Reimbursement for physicians treating MA beneficiaries can differ significantly from traditional Medicare. MA plans often utilize different payment models, such as capitation or bundled payments. Physicians must understand the specific billing guidelines and contracts established with each MA plan. Although MA plans provide Part A and B coverage, physicians will still bill for their professional services and will not be directly reimbursed under Part A as defined in the original Medicare structure.
| Feature | Traditional Medicare (Parts A & B) | Medicare Advantage (Part C) |
|---|---|---|
| Administered by | Federal Government (CMS) | Private Insurance Companies |
| Coverage | Parts A & B benefits directly | Parts A & B benefits managed by private plan |
| Physician Billing | Direct Part B billing | Varies by plan (FFS, capitation, etc.) |
| Network | Generally no network restrictions | Network restrictions often apply |
Implications for Physician Practices
Understanding the complexities of Medicare reimbursement is crucial for the financial health of physician practices. Failing to adhere to billing guidelines can lead to significant revenue losses. Invest in proper training for billing staff and stay updated on the latest Medicare regulations.
Frequently Asked Questions (FAQs)
Can a physician bill for services provided during a patient’s inpatient hospital stay?
Yes, physicians can bill Medicare Part B for their professional services rendered during a patient’s inpatient hospital stay covered under Medicare Part A. The key is that they are billing for their professional services, not the facility costs.
What is the difference between “incident to” billing and shared visit billing?
“Incident to” billing allows a physician to bill for services provided by an NPP under their supervision, meeting specific criteria. Shared visits involve both a physician and an NPP seeing the patient during the same encounter, with specific rules determining which provider bills for the service based on the substantive portion of the visit.
How do I ensure my claims for physician services in a Part A setting are not denied?
Ensure accurate documentation of medical necessity, use the correct place of service codes, avoid duplicate billing for services already covered under Part A, and utilize appropriate modifiers. Thorough training for billing staff is essential.
What is the Medicare Physician Fee Schedule (MPFS)?
The MPFS is a comprehensive list of payment amounts Medicare uses to reimburse physicians for their services. It includes the relative value units (RVUs), geographic practice cost indices (GPCIs), and conversion factor used to calculate payment.
What is the Stark Law and how does it relate to physician reimbursement?
The Stark Law prohibits physicians from referring patients to entities with which they have a financial relationship (including ownership), if those entities bill Medicare. This law aims to prevent self-referral and ensure that medical decisions are based on the patient’s best interests, not financial gain.
What are bundled payments and how do they affect physician reimbursement?
Bundled payments are a reimbursement model where Medicare pays a single payment for all services related to a specific episode of care. While hospitals receive the bundled payment, physicians can be included in the arrangement, and the hospital might negotiate separate contracts to reimburse them for their services provided during that episode. Physicians are not directly reimbursed by Medicare under the bundled payment.
How often does Medicare update its billing guidelines?
Medicare updates its billing guidelines frequently, typically on an annual basis, and often with mid-year updates as well. It is crucial to stay informed of these changes to ensure compliance and accurate billing.
How do Medicare Advantage plans affect physician reimbursement for Part A services?
Medicare Advantage plans have their own reimbursement policies. Physicians must familiarize themselves with the specific contracts and billing guidelines of each MA plan they participate in. While MA plans manage Part A benefits, physicians bill for professional services.
What is the role of a Medicare Administrative Contractor (MAC)?
MACs are private companies that contract with Medicare to process and pay Medicare claims in specific geographic regions. Physicians submit claims to their designated MAC, which is responsible for determining payment and handling appeals.
What resources are available to help physicians understand Medicare billing?
CMS (Centers for Medicare & Medicaid Services) provides a wealth of resources on its website, including the Medicare Learning Network (MLN), provider manuals, and fact sheets. Professional medical associations and billing software vendors also offer valuable training and support.
What happens if a physician knowingly submits fraudulent claims to Medicare?
Submitting fraudulent claims to Medicare can result in severe penalties, including fines, exclusion from the Medicare program, and even criminal charges.
What is the difference between a participating and non-participating physician in Medicare?
A participating physician agrees to accept Medicare’s approved amount as full payment for covered services. A non-participating physician can choose whether or not to accept assignment (accept Medicare’s approved amount), and may charge patients up to 15% above the Medicare-approved amount (limiting charge).