Medicare and the Medical Assistant: What to Know


Article Categories: Other & Medical insurance

As the Baby Boomer generation ages, the number of people receiving Medicare benefits is skyrocketing every year. People born between 1946 and 1964 are turning 65 at the rate of 10,000 a day. For healthcare professionals, this means more elderly patients with chronic illnesses or special needs who will be seeking medical care in your setting.



Medical Assistants have probably already seen the rise in older adult patients. Routine office visits account for the largest share of Medicare billings. Whether you have administrative and accounting responsibilities, or are involved in patient care, there are a few things to know about Medicare and how it can impact your job and the practice.

1. Medicare is the federal health insurance program for anyone who receives Social Security. Medicare recipients are called “beneficiaries.” About 83% of beneficiaries are over age 65. Almost 16% are people who are disabled and qualify for Social Security. A tiny 1% are patients in the End-Stage Renal Disease program; they are eligible for dialysis, regardless of their age.

2. Get ready for a surge of Medicare patients! In 2010, there were 47.4 million beneficiaries. By 2020, there will be 63.9 million...going all the way to 112 million in 2080.

3. Medicare is considered an effective program by beneficiaries. About 97% of providers accept it for payment, all over the country. Even the 3% who don’t accept it are bound to honor the reimbursement rate; they cannot charge more than 15% of the Medicare “limiting charge.”

4. When physicians decide to participate in the Medicare reimbursement program, they look at the fee schedule and “accept assignment,” meaning they agree to accept the rate Medicare sets as the price for that service. Medicare will pay 80% of the set amount for each service. The patient will be responsible for the rest.

5. In 2012, the Centers for Medicare and Medicaid Services (CMS) released an analysis of Medicare payments for Part B, which covers reimbursements for physician services. About 19% of the practice’s money comes from Medicare. The report said, “For a $70 evaluation visit, Medicare usually pays about $49 and the patient or their private insurer covers the rest.”

6. Correct coding is essential for reimbursement and to keep the practice solvent. Getting paid from Medicare involves three things:

• Proper coding of the service using Current Procedure Technology (CPT)

• Proper coding of the diagnosis using ICD-9 code

• Determining the fee based on the Resources-Based Relative Value Scale (RBRVS) established by (CMS)

If coding isn’t accurate, Medicare can bump the payment to the next cycle, which can add up to 45 more days before reimbursement arrives. This delay can have a severe impact on the practice.

As a practice-based healthcare professional, the Medical Assistant can play an important role in maximizing the office routine for efficient patient care and accurate coding, as well as minimizing any delays in reimbursement. Medicare will continue to grow as a source of the practice’s income. Learning how it works will make you an even more valuable team member.

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