At AMS Solutions, we understand more than most that dealing with unpaid medical bills can be one of the most stressful, confusing, and even overwhelming tasks, particularly when there are problems with getting the bills paid by your insurer. You may even be at the point where you’re wondering, “Can you sue an insurance company for not paying medical bills?” This question is a lot more common than you may think, particularly when patients may find themselves stuck in a frustrating situation with their insurance providers. 

Understand Your Rights

First of all, you must understand your rights, however, the insurance landscape can be incredibly complex. In some cases, the answer to “Can I sue my medical insurance company” is a definite yes. That said, like many other things it is not as straightforward as it seems. 

Before rushing out to file a lawsuit, however, you’ll need to ensure that you’ve exhausted all of the other possible solutions or remedies. This can include filing an appeal directly with the insurance company, seeking the intervention of an insurance regulator, or even getting a patient advocate involved. 

When Can You Sue an Insurance Company?

If your insurance provider is not adhering to the terms of the contract that they hold with you, your insurance policy, then it is possible to sue for a breach of contract. This is often the case when a particular insurance company denies a claim without any reason, when they’re delaying payment intentionally, or when they refuse good-faith out-of-network rate negotiations as may be required by their policy. The biggest hurdle is that the legal process can be lengthy and quite costly to pursue in some situations. This is where the services AMS Solutions provides can be of incredible value.

The Value of Expert Assistance

When you’re dealing with an issue as serious as unpaid medical bills, expert assistance can make all of the difference in your case. If you’re asking “Can I sue my medical insurance company?”, it may be time to talk to a professional about it. AMS can offer you that much-needed assistance. We are well-versed in the intricacies of insurance policies and have a solid track record of helping to resolve complex billing issues. 

How AMS Solutions Can Help

The expert billing professionals at AMS have extensive expertise not only in coding and billing but in collections. This means we’re uniquely equipped to help you navigate the incredibly complex billing situations that have you wondering if you can sue your insurance company for not paying your medical bills. 

We can help you explore viable solutions, and our team of insurance experts can review your coverage, and help identify any potential inconsistencies in the denial issued by the insurer. For those trying to appeal insurer determinations, this can be invaluable. In many cases, it can even lead to a satisfactory resolution without resorting to legal action. 

The Best Course of Action – Partnering With AMS

Can you sue an insurance company for not paying medical bills? While the answer is yes, it’s important to remember that it should be the last resort. It’s often found to be more cost-effective and more efficient overall. This is generally because the more efficient and cost-effective option is to resolve these issues with the help of experienced and trusted professionals, like the ones at AMS Solutions. 
Instead of feeling overwhelmed by the prospect of legal action against your insurer, why not start with more manageable steps? First, reach out to AMS and let us help you explore your options and find the best solution together.

Every industry is rapidly moving toward complete digitization, and the healthcare industry is certainly no exception. Unfortunately, a world that is moving constantly toward more digital solutions will undoubtedly face mounting concerns over growing problems like medical billing fraud. 

We’re going to take a look at what exactly medical billing fraud is, as well as go over a step-by-step walkthrough of how to report it. We’ll also discuss how AMS Solutions is uniquely positioned to be an effective, ethical, and error-free partner in outsourced medical billing. 

What Is Medical Billing Fraud?

Medical billing fraud typically involves false claims or statements being made in relation to healthcare services. This means medical billing fraud can take many different potential forms, including billing for services not performed, double billing, or misrepresenting the services rendered. Fighting these unethical and illegal practices helps to be able to recognize and report instances of medical billing fraud.

How to Report Medical Billing Fraud: A Step-by-Step Approach

1. Document Everything: The first and most important step in billing fraud reporting is documentation. Keep a record of every detail related to the suspected fraudulent billing. This includes dates, service descriptions, amounts billed, and records of any conversations you had with providers or insurers.
2. Contact Your Insurance Company: Once you have gathered together all of the needed information and documentation, the next step is to contact your insurance company. They will generally have a dedicated fraud reporting hotline, and they will guide you in their specific fraud reporting process. 
3. Report To Authorities: If your insurance company doesn’t, or isn’t able to, resolve the issue, or if you suspect they may be involved in the fraud, it’s important to escalate the matter to the appropriate local, state, or federal authorities. This can include the state insurance commissioner’s office, the Federal Trade Commission (FTC), or even the Office of the Inspector General (OIG).
4. Get Legal Help & Representation: If the fraud has resulted in you suffering financial harm or other measurable damages, you may have the right to pursue compensation, but you’ll likely need to get an attorney involved. Consulting with a lawyer will often not only be able to get you answers to your questions, but it can get you guidance on the process, and may even result in the attorney taking the case on contingency.

Partner with AMS Solutions for a Fraud-Free Experience

Understanding how to report medical billing fraud is a critical skill in the modern highly digital healthcare landscape. By staying highly vigilant, you can help fight this unethical practice, ensuring that everyone pays their fair share for healthcare services. Remember, however, that prevention is the best strategy, and while understanding how to report medical billing fraud is essential, doing everything you can to prevent it is even better.

Partnering with one of the most trusted leaders in the medical billing services industry, like AMS Solutions, can go a long way toward providing you with peace of mind regarding your practice. Choosing a reliable billing partner like AMS means that you can count on your coding, billing, and collections to be handled in a professional, ethical, and legal manner that helps protect patient data integrity and security.
At AMS Solutions, we’re also committed to transparency and integrity in all aspects of our operations. We adhere to all local, state, and federal regulatory requirements, and ensure that all billing practices we engage in are accurate and compliant. We employ a robust checks and balances system to prevent any chance of fraudulent activity, providing a safe and reliable billing service for all of your organization’s needs. Reach out to AMS Solutions today to learn more or to get started making the switch.

Both Medicare and private insurance plans use many different methods to identify and avoid incorrect or improper payments. The methods and tools used can vary depending on the review type, and whether they are used in the pre-payment or post-payment stage. 

Both are important, but understanding pre-payment review is the first step in understanding the beginning of the payment review process. Pre-payment review in particular can help prevent improper payments, saving money from day one.

What Is Pre-Payment Review?

The Medicare insurance pre-payment review is a simple step in the claims process. It is the review of a claim before it is paid by the insurer. In some cases, the pre-payment review can result in the denial of the payment. The pre-payment process includes medical review as well as the application of edits where needed. An edit can provide automatic verification of certain claim details, even across sets of claims, so make sure they meet the criteria for payment. Edits are applied by processors between submission and payment of claims.

When Is Pre-Payment Review Required?

Pre-payment review is when Medicare, or potentially any private insurer, wants to review all of the claims from a particular office or facility before they pay them.

This often happens when using a doctor, facility, or office that has had a history of claims that resulted in improper payments. In many cases this could be because they’ve submitted documentation that doesn’t support the coding, unnecessary services, billing inconsistencies, and more. Sometimes, payers determine that there is an anomaly in claims that is traceable to other providers in the region.

What Is The Pre-Payment Review Process?

In general, there are two primary types of pre-payment reviews, the complex, and the non-complex. The complex review is going to require documents aside from the claim itself, such as medical records or consultation to review the validity of the claim. The non-complex review isn’t going to require any additional documentation.

There are three criteria on which reviews are based. These are National Correct Coding Initiative edits, edits classified as Medically Unlikely, and Medical Review. Both the National Correct Coding Initiative edits and Medically Unlikely edits will generally be non-complex reviews.

Medical review, however, can be a relatively complex process. It will usually be performed by Medicare Administrative Contractors or Supplemental Medical Review Contractors, and the review contractors will focus Medical Review activities specifically on the already-identified problem areas, and will determine the action to take based on the severity. These actions can include:

• Pre-payment review
• Post-payment review
• Education or feedback for the healthcare provider

If the decision made is to enact pre-payment reviews, the insurer or payer will ask the provider to send pertinent records and other documents for any claims made within a predetermined time frame. In many cases the records period is three month’s worth, but in some rare cases they can go much further back.

Ending Pre-Payment Reviews

To remove pre-payment reviews, providers or coders should first review all of the pertinent medical records and double-check that all codes used are supported by the medical records. Additionally, they should make sure that their billing and coding department is adhering to the requirements of each insurer when actually assigning codes or creating billing claims. Coding and billing staff should also be trained to properly check for bundling and unbundling of codes.

AMS Solutions Can Help Prevent Pre-Payment Reviews

When it comes to preventing or avoiding pre-payment reviews, AMS Solutions can provide coding and billing professionals that are kept up-to-date and completely educated on all aspects of claims billing.

What Is Concurrent Review By An Insurance Provider?

Many people wonder what the standard concurrent review definition is. A concurrent review is a review that takes place while the patient is actively receiving care during an admission to a healthcare facility. The concurrent review’s purpose is to have some framework for oversight during treatment that allows examination and scrutiny of the type of care that is being administered to the patient. It also evaluates the necessity for that level of care, as well as the setting.

Why Are Concurrent Reviews Needed?

The goal of concurrent reviews is to make sure that healthcare is delivered effectively and efficiently, to reduce or prevent the improper use of inpatient medical services and treatment, and to ensure that all patients receive the high quality of care that is indicative of inpatient treatment. It works similarly to prior authorization, in that the concurrent review can help foster more effective communication about the patient to various areas or departments of the healthcare organization itself. 

Additionally, concurrent reviews also help provide access to other health services and support features that may help with the coordination or continuation of care, particularly in regard to transitions from one level of care to the next. This may be either discharged to a care facility, or even to their home. A concurrent review is also able to identify patients that may benefit from various care methods, including case or disease management, or any number of other options depending on the diagnosis and treatment needs. 

The Concurrent Review Process

The concurrent review process is designed to optimize care during a hospital or treatment facility admission. The goal is to ensure that the patient receives the right care, right when it’s needed and that the treatment is in line with the insurance plan and coverage requirements. The concurrent review process includes aspects such as:

• Collection and aggregation of all patient information directly from the care team regarding their condition and progress in treatment
• Evaluating patient treatment information from the care team to determine treatment coverage
• Maintaining informative communication between all parties involved in the patient’s care when a decision regarding coverage is made
• Identifying situations when patients may be given a discharge and continuing care plan early in the stay
• Continual evaluation and assessment of the care plan during the stay
• Identifying and referring any potential concerns about the quality of care or patient safety that may require additional review

Concurrent Review vs. Peer Review

A concurrent review is functionally much different than a peer review when it comes to the process by which they happen, as well as the goal of each. The concurrent review process is an ongoing process that should be happening seamlessly as a part of all levels of care for an insured individual. 

The peer review process, however, is meant to address specific and often highly complex treatment needs on an ad hoc basis. This process consists of any current treating practitioner submitting a request to consult with a medical health professional within the insurance company. Often this is to discuss a utilization issue or to go over needed care that may be required for long-term care services and other continued care support services.

AMS Solutions Can Optimize Your Coding For Review

One of the biggest factors in ensuring your organization is paid promptly and correctly is leveraging expert billing and coding professionals. With more than 30 years of experience in the billing, collections, credentialing, and practice management fields, you can trust that AMS Solutions will be an effective coding and management partner. 

If a healthcare patient’s claims are denied, not only will they often wonder why claims are not being processed, but they may still submit claims that are inaccurate. Here are some of the common reasons that claims are denied.

Top Reasons Why A Claim Is Not Being Processed

Missing Or Incomplete Patient Info

An incredible portion of claim denials are administrative or clerical in nature and originate at the front desk. This means things like patient data oversights, such as a missing patient subscriber number, missing date of birth, and incorrect insurance eligibility are all routine reasons that a claim is denied. 

Basic Claim Form Errors

A huge portion of claim rejections is known to be caused by “simple errors” in either the patient data or in the procedure codes. This can be something as simple as a misplaced letter in the last name, or a patient ID number having two digits transposed. These errors are usually very quick and easy errors to fix, but they stretch out the revenue cycle, so they should be avoided if at all possible. 

Lack Of Official Documentation Supporting The Claim

Claims that have a component of medical necessity will need documentation or records that support that designation. In situations like this, the payer will often require additional support documents that not only illustrate medical necessity but also support the level of service.

Insufficient Medical Necessity

Even when substantial amounts of documentation and medical records are provided, occasionally a payer will simply decide that a procedure or treatment isn’t medically necessary. This can be a difficult situation for everyone involved, but in some cases, it can be avoided. 

The best way to fight insufficient medical necessity denials is to have good communication between your clinicians and coding staff. When a claim is denied, for this reason, the doctor’s office or provider may be forced to absorb the treatment cost, or they may be able to collect the full amount from the patient, which isn’t very likely. 

Pre-Authorization Or Pre-Certification Was Not Obtained

There are many situations that warrant getting pre-authorized to perform some type of care. Knowing which insurers require pre-authorization and what they require to authorize coverage is essential for your coding and billing team. Depending on what coding or billing software is used, there may even be built-in measures for highlighting certain procedures and special insurers.

Claims Filed After Deadline

With all of the different insurers out there, it’s no surprise that many of them have different deadlines for submitting claims, and have varying degrees and policies for exceptions when deadlines are missed. Some payers can fix a missed submission with a quick phone call, while others will require a more clerical and administrative fix by having you fill out some paperwork to get the issue fixed.

The Provider Used Was Out-Of-Network

Insurance companies and their networks can change drastically from one year to the next, and while many patients don’t realize it, this includes the various doctors and healthcare providers they have partnered with. To be sure that claims, benefits, and payments are made in full for your treatment and doctor’s appointments, use a doctor or facility that is in-network. While this may not mean that everything is covered, significantly more of the services that you need will be able to be obtained in this way. 

Prevent More Denials With AMS Solutions

Your billing matters and claims denied for simple and preventable mistakes. Ensure that your medical billing support is all properly trained in the methods that your biggest payers require by partnering with AMS Solutions.

Those who work in the medical field have a significant amount of responsibility. Not only the doctors and nurses who treat you but also the coding and billing professionals that work behind the scenes on paperwork and medical records. There are countless medical regulations and processes that go into medical coding, and it is crucial that the coding is done properly. We’re going to look at what proper coding is, and exactly what is the importance of knowing proper CPT coding.

What Is A CPT Code?

CPT stands for Current Procedural Technology, and CPT codes create a uniform reporting and coding language that is used to make reporting easier, as well as more efficient and accurate. CPT codes are used for medical billing that is either five digits, or four digits and one letter long, and they indicate medical or administrative management procedures. They are used for claims processing as well as for the creation and modification of medical care review guidelines.

Why Is Proper CPT Coding Important?

Most medical facilities rely on insurance providers for the majority of their funding and revenue. Other sources like healthcare programs contribute as well, but the greatest portion is provided by insurers. Insurance companies make their money by charging policyholders a premium, or fee, that is often paid monthly. Since there are many more people who have insurance than are sick at any one time, it allows the insurers to cover most of the medical expenses or costs for those who hold policies. That said, there is a huge portion of income coming from reimbursements, and a very tiny share coming from patients’ pockets. 

This is why proper CPT coding is so crucial. Every single patient that visits a hospital, care center, or doctor’s office has a file of medical records that need to be kept updated and accurately documented. If the coding and billing are done incorrectly, it can result in the hospital losing significant amounts of money in lost reimbursements. Additionally, accurate and correct billing and coding are needed to ensure that patients are being charged more than they should be and that their respective insurer is charged the correct portion of the costs.

Types Of CPT Codes

There are codes assigned for every potential procedure or service that medical providers can provide or perform. CPT codes even include many unlisted codes for procedures or special services that are not specified in other unique CPT codes. There are three categories of CPT codes created by the AMA, the categories are:

CPT Category I

Category I contains the largest body of standard codes. These are the codes most commonly used by healthcare providers to report frequently used services and procedures.

CPT Category II

Category II contains supplemental codes that are used for performance management and other administrative purposes. There are codes relating to patient history, diagnostics, patient safety, and follow-up procedures.

CPT Category III

CPT Category III contains the most infrequently used CPT codes. It also contains temporary codes that are used to code and bill experimental services, rare procedures, or emerging treatments. 

Understanding CPT Codes And The Importance Of Proper Coding Is Vital For Accurate Recordkeeping

Hopefully, we’ve been able to shed some light on just why proper CPT coding is so essential to the continued operation of healthcare facilities. Without accurate and proper CPT coding, patients would be charged wrong amounts for procedures they never had performed, and the facility would lose out on potentially millions in insurance reimbursements. This can jeopardize not only the health of patients but the longevity of the medical facility as well. 

Are you looking to get into the medical billing career field? Then it’s important that you know what that job will entail based on the type of facility you’re working for. There are clear differences between billing between healthcare and other industries within the medical field. The processing of medical claims across varying facility types and specialties is significantly different. No matter what, medical billers work with one of two types of billing: institutional billing or professional billing. We’re going to look more closely at the differences between facility vs professional claims.

What is Professional Billing?

The staff in a doctor’s office handles many different tasks, from greeting patients and getting them checked in, to scheduling appointments and collecting money. Medical billing is also handled within the office as well. The claims that are generated for the work done by suppliers, physicians, and other non-institutional providers are considered professional billing.

These professional charges are billed on the standard CMS-1500, which is a red ink on white paper claim form that both suppliers and physicians use for claim billing. Not all claims are billed on paper. Most insurance companies, including Medicare and Medicaid, primarily accept electronic claims. When the claims are submitted electronically, it’s the 837-P rather than a CMS-1500.

What is Institutional Billing?

Institutional billing is the billing of claims for work done by institutions. Healthcare facilities like hospitals, nursing homes, and similar facilities that offer inpatient and outpatient services use institutional billing. Not only will it include services performed by the facility, but also the use of various pieces of equipment, the use of laboratory services, radiological imaging services or equipment, and more.

Biggest Differences Between Billing Types

When you compare the basics, it may seem like there isn’t much difference between professional and institutional billing. However, there are some key ways they are separated. The biggest differences between a facility claim vs a professional claim are the duties available as well as the types of forms used. 

Different Forms

Professional billing claims are billed using a CMS-1500 form. The CMS-1500 is a standard form that has red ink on white paper. It is used not just for physicians, but for supplier claim billing as well. If the billing is done electronically, the digital version of the CMS-1500 is the 837-P, with the P standing for professional claims.

Institutional claims are billed using a form called a UB-04. The paper version of this form is also red ink on white paper and is used for the physical billing of institutional charges. The electronic version of the UB-04 is the 837-I, with the I standing for institutional claims.

Roles Addressed

When looking at professional vs facility billing, there are unique claims for different industries and jobs. Facility claims deal with hospital and laboratory services, while professional claims are for physicians that work in medical offices.

Duties and Skills

Regardless of the type of billing, professional vs. facility, medical billing professionals have a crucial responsibility. Medical billers must learn about five distinct areas of billing, including:

1. Understanding how to obtain or use information about each insurance company to submit claims efficiently.
2. Knowing how to perform their duties while maintaining medical confidentiality and avoiding HIPAA violations.
3. Having a working familiarity with the specific billing software that is used will result in massive time savings for training, will reduce errors, and prevent issues and headaches in general.
4. Understanding that coordination of benefits information is vital and that submitting claims in the proper order reduces delays in payment.
5. Understanding that each portion of a medical claim is representative of information collected during the entire time from patient scheduling through treatment.

Prior authorization, or PA, is a requirement for certain medications and treatments. Before you can receive the care you need, your insurance company may need to grant approval first. Sometimes the process is handled before you get to the pharmacy, while other times you may be told you have to wait for your insurance provider to allow you to get the prescription through them. Let’s take a closer look at everything you need to know about prior authorization for medications.

What is Prior Authorization for Medication?

So, what is a prior authorization? Before a physician is able to administer certain medical procedures, devices, or specific medications, they may need to follow the process to get approval from your insurance company. Prior authorization has to be requested before the request for your insurance to cover all or a portion of your treatment. Your physician’s request may even be denied.

Why a Prior Authorization is Required by Insurance

According to health insurance companies, prior authorization is required for some treatments, medications, procedures, and medical devices to keep the cost of healthcare lower.

Medications That Need PA

Prior authorization is a requirement for several different medications. The request may be necessary for a number of reasons, including:

• The medication is expensive (such as rheumatoid arthritis and psoriasis medications)
• There is a cheaper generic version available and the physician is requesting the brand name
• Used to treat conditions that are non-life threatening
• Used at doses higher than normally recommended
• Cosmetic use (such as wrinkle treatments and hair growth)
• Your physician deemed it medically necessary (if this is the case, they need to inform the insurance company that other medications that are covered will not be effective forms of treatment for you)

How to Tell if You Need Prior Authorization

Finding out if your insurance company requires prior authorization is easy. Calling your insurance company and asking them directly is a good way to go. Otherwise, your pharmacy will inform you if prior authorization has been requested by your doctor when you go to fill or pick up the prescription. If it has not been approved, they will charge you the full amount.

How Prior Authorization Works

When your doctor requests a prescription for you, they should contact your insurance for prior authorization. If they did not, however, your pharmacy will contact the doctor to let them know the authorization is required. Once they are aware that approval needs to be requested, your doctor or a member of their staff will reach out to your insurance to get the forms filled out and submitted. This can take a while, depending on your insurance company.

In addition to the paperwork your doctors’ office submits on your behalf, your insurance provider may also require you to fill out some forms as well. You should call them to see if there is anything you need to do on your end before they review and approve your request. Once the insurance company has made its decision, it will contact you, your doctor, or your pharmacy about whether the request was approved or denied.

How Long Does it Take?

In most situations, prior authorization takes a few days to process. The specific time frame depends on what type of medication or procedure your physician has requested, along with the insurance company you have. If you haven’t heard anything by a week after your initial discussion with your doctor, you can contact the pharmacy to see if the request was approved. If your submission was not approved, the next step is to contact your insurance company directly to find out why the request was denied or delayed.

Deductible vs. out-of-pocket is a common question asked by people who are considering health insurance and even by health providers who aren’t often experienced in medical billing terms and services.

The Difference Between Deductible and Out of Pocket in Health Insurance

Out-of-pocket healthcare costs, also known as copayments or coinsurance, are a set amount of money that you’re required to pay for certain services on top of what your insurance covers. With deductibles, there are monthly payments that you make before your insurance starts to cover anything at all.

The deductible is the amount that must be paid by the insured before their insurer will start paying for medical care, and it varies depending on the type of plan chosen. An individual may have to pay up to $2,000 in medical expenses before their insurer starts paying anything at all, while a family might have to pay up to $6,000 in medical expenses before the insurer starts picking up more than 50%.

This means that those with higher deductibles can end up paying a lot out of pocket for health care, which is why many choose to have higher monthly premiums to cover that cost. Some plans may offer lower deductibles for a monthly premium increase.

Other plans with slightly higher premiums may have higher deductibles. The type of plan chosen should be based on each individual’s own needs and preferences, so it is best to consult a financial advisor before choosing a plan.

What is a Deductible?

A deductible is the amount of money that a person must pay out-of-pocket before their insurance company will start paying for a medical service. Deductibles are most common in health insurance plans, but some other types of insurance have them as well.

The purpose of a deductible is to encourage people to be more careful about how they spend their healthcare dollars. For example, if you have a $500 deductible, it will take you five months to reach the point where your insurer starts paying for your care. This means that you’ll spend less on healthcare and be more careful about what services you need and how often you use them.

What is an Out-of-Pocket Maximum?

The out-of-pocket maximum is the most you will pay for your health care services. The out-of-pocket maximum is one of the key features of a health insurance plan. The maximum out-of-pocket amount is the most a person will pay for covered medical expenses. It’s what determines how much you will have to pay for your medical services in a given year.

The out-of-pocket maximum can be different from one plan to another, but it’s usually set at a certain dollar amount. For example, the average in 2018 was $3,000 per family. Unfortunately, not everyone can afford to pay out of pocket.

Why Do Some People Pay Out of Pocket?

The Affordable Care Act (ACA) requires that all Americans have health insurance coverage. However, some people are not able to afford the monthly premiums.

Some people may not be able to afford the monthly premiums because they are living paycheck-to-paycheck and cannot justify spending money on something they don’t need like health insurance. Other people may be eligible for Medicaid but do not know how to enroll or don’t want to take advantage of any government assistance programs that are available.

While some people may be eligible for Medicaid, they will often find that the Medicaid plans have high deductibles and copays which can make it difficult for them to get the care they need when needed.

In addition, many doctors are not accepting new Medicaid patients due to low rates of reimbursement from the federal government. If you need help with figuring out insurance policies and terms for your healthcare practice, please contact us today. You can also visit our detailed FAQ at your convenience.

Contracting with insurance companies can be a tricky business for a healthcare provider, but it doesn’t have to be. With the right information, you can make sure that your company is not only covered but also that you are getting the best possible deal. There are many aspects to consider when contracting with insurance and there are many different types of insurance providers and plans.

Healthcare providers should always contract with Medicare or Medicaid. These two insurance providers are a good option for anyone entering the healthcare field because they give you a lot of leeway in terms of what you’re allowed to charge. In other words, if you don’t have experience, these two insurance providers will give you the opportunity to build it.

What is a Medicare/Medicaid Contract?

A Medicare/Medicaid contract is a legal document that outlines the terms and conditions of a business agreement between a healthcare provider and an individual, organization, or government agency.

The Medicare/Medicaid contract is used to describe the services offered by the healthcare provider. It also includes information about the billing process and how payments will be made. The contract specifies that any medical services provided to patients covered by Medicaid must be at no cost to them. The patient may be asked for co-pays for other services not covered by their insurance plan.

This contract is also used when patients are enrolled in Medicare Part B or D plans. The patient may need to sign this form in order to receive coverage from their insurance company for any medical service provided by the healthcare provider on their behalf, regardless of whether they choose to pay the provider or not. The terms and conditions of the Patient Acknowledgement form are set by the healthcare provider who has contracted with Medicare Part B or D.

What Kind of Health Coverage Does A Medicare/Medicaid Contract Provide?

Medicare is a national health insurance program for people who are aged 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare offers healthcare coverage for hospital stays, doctor visits, medical equipment, and other medical services.

Medicaid is a joint federal and state program that helps pay health care costs for some people with low incomes and limited resources. Medicaid provides health coverage to millions of children, adults, and seniors near or below the poverty line who meet certain eligibility requirements.

How to Get Started with a Medicare/Medicaid Contract?

The Centers for Medicare and Medicaid Services (CMS) has a website that provides information on how to get started with a Medicare contract. This website is the first place to start if you are looking to become a Medicare provider.

There are two ways in which CMS can award contracts: “competitive bidding” and “no-bid.” The competitive bidding process is open to all providers, while the no-bid process is reserved for providers who have been awarded contracts in the past.

In order to participate in competitive bidding, you must submit an application and then wait for CMS approval. If your application is approved, then you will be awarded a contract if the bid amount exceeds your competitors’ bids by 10%.

Let AMS Solutions Get You Contracted with Medicare/Medicaid

AMS Solutions is a billing company in Dallas that specializes in Medicare/Medicaid contracts. We have a team of professional, certified, and licensed coders who are experts in the healthcare industry. We can work with any insurance company and they provide the best customer service. We will take care of all your needs and provide you with the highest payout possible.

Contact us today if you need help with getting your healthcare practice contracted with Medicare or Medicaid. We’ll answer any questions or concerns you may have about working with us.