INTRODUCTION

Medical billing and coding is a crucial step in the healthcare industry and connecting patient care to medical reimbursement can become very complicated. This section is designed to help physicians and their staff with the billing, coding, and payment side of healthcare delivery. This section contains link to various payers, information on how to appeal and dispute denied services, how to appeal recoupments, where to file complaints and information on current topics that could collectively impact the billing process.

APPEALS AND DISPUTES

  •  Appeals and Dispute Process - This section contains information for the appeal and dispute process for each major payer.

BILLING CHRONIC CARE MANAGEMENT SERVICES

  • This section provides information on how to appropriately bill for the new Chronic Care Management code 99490.

BILLING FOR DUAL - ELIGIBLES

  • CMS has conveyed their concern that some physicians are billing Qualified Medicare Beneficiary (QMB) also known as (Dual Eligible) beneficiaries. The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries — e.g., individuals who are enrolled in both Medicare and Medicaid - with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers - even those who do not accept Medicaid - from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice. 
    • For additional information, see MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program. 
     

BILLING FOR INTERPRETATION SERVICE FOR THE HEARING IMPAIRED

PAYMENT ASSISTANCE PROGRAM

  • The Harris County Medical Society (HCMS) has a payment assistance program available to our members to help assist them with payment issues. To learn more about this program please visit our Payment Assistance's website.

PHYSICIAN EXTENDERS

  • This section contains information on physician extenders.

PROMPT PAY DISCOUNTS

  • This section contains information on prompt pay discounts.

RECOUPMENTS

  • This section contains information on recoupments regarding fully insured, self funded, and government plans.

TEXAS PROMPT PAY- (Fully Insured Plans)

  • On June 17, 2003, Governor Perry signed into law SB 418 also known as Texas Prompt Pay to help physicians receive payment for services promptly.  

 WHERE TO FILE COMPLAINTS 

  • This section contains information on where complaints can be filed.