Scope for each practice is confirmed in the engagement agreement, including systems, payers, and queues.
Government-program denials often repeat a rule the office already knows
A missing ABN when a service may not be covered, a clinician who is not PECOS-enrolled, or a Medicaid prior authorization that differs from the commercial plan next to it will deny in a pattern. Staff who are excellent at commercial follow-up still miss these because the edit is not in their commercial scrubber. The fix is a separate lens, not a louder appeal letter.
What the work includes
- Confirmation that the billing and rendering providers are enrolled for the program being billed
- Medicare-specific modifier and medical-necessity checks for the specialties in scope
- Advance Beneficiary Notice handling when the practice chooses to use one for a statutory exclusion or a frequency limit
- Medicaid state-policy notes for the states the practice actually bills
- Secondary-payer sequencing when Medicare is not primary
- Remit posting that respects sequestration, deductible, and coinsurance as different buckets
How the work moves
Step 1
Confirm program and sequence
Medicare as primary, Medicare as secondary, Medicare Advantage, and Medicaid are not billed on the same mental template. The registration has to say which one applies.
Step 2
Apply program edits
Frequency limits, covered diagnosis expectations, and required modifiers are checked for the codes the specialty uses most. The checklist is narrower than the entire manual, and it is dated.
Step 3
Handle patient cost share correctly
Deductible, coinsurance, and a noncovered service are posted differently. A Medicaid copay rule is not copied from a commercial card.
Step 4
Escalate policy questions
Local coverage questions that the checklist cannot answer are written down for the practice. We do not invent a covered diagnosis.
Operational benefits
- Fewer repeated Medicare front-end rejections
- Clearer posting of deductible and coinsurance
- Medicaid work that follows the state the practice is enrolled in
- A visible list of rules that actually hit this specialty
Common challenges
- Medicare Advantage plans add commercial-style auth rules on top of Medicare coding
- Medicaid policies differ by state and by managed care organization
- Local Coverage Determinations change and are not identical in every jurisdiction
- An ABN used for the wrong reason creates its own compliance problem
Technology
Eligibility transactions can identify many Medicare and Medicaid plans and still miss managed-care details. Enrollment status is confirmed in the relevant payer system. We do not claim a private connection to CMS beyond the transactions and portals the practice is allowed to use.
Where specialty changes the work
Therapy thresholds, chiropractic AT modifier use, nephrology monthly capitation, and preventive Medicare visits are specialty problems described on those pages. This service holds the program rules those pages rely on.
Questions
Do you bill Medicaid in every state?
Only where the practice is enrolled and the engagement lists that state. Medicaid is not a single national payer.
Will you tell us which diagnoses make a service covered?
We can point to a published policy and compare it with the note. We will not add a diagnosis so a claim will pass.
Are Medicare Advantage claims just Medicare claims?
They use Medicare benefit structure and often a plan's own authorization and portal rules. Treating them as identical to traditional Medicare is a common source of delay.