How to Bill Medicare as a Healthcare Provider: A Practical Guide

In the ever-evolving healthcare industry, mastering Medical Billing is essential. As of April 2024, over 67 million Americans rely on Medicare, representing nearly 20% of the U.S. population. With such immense scope, even small inefficiencies in your medicare billing process can cumulatively cost providers millions annually.

Providers across the country are experiencing this. 84% indicate that reducing claim denials is a top priority, and 73% report that denials have increased in the past two years. The result? Slower reimbursements, higher administrative burden, and delayed patient care make billing expertise more vital than ever.

In this blog, you’ll learn how to bill Medicare as a provider, covering essential steps, common pitfalls, and actionable tips to avoid denials and maximize reimbursements.

Who is a Medicare Provider?

A Medicare provider is any healthcare professional or facility authorized to offer services covered by Medicare.

1. Individual Providers: Licensed professionals like doctors, therapists, and nurse practitioners who can bill Medicare directly.
2. Institutional Providers: Healthcare facilities like hospitals and nursing homes that provide Medicare-covered services and must meet CMS compliance standards.

How to Enroll as a Medicare-Approved Provider

 Before you can begin billing Medicare, you first need to become an enrolled Medicare provider. The Centers for Medicare & Medicaid Services (CMS) has laid out a clear process to help healthcare professionals and organizations get credentialed. Your first step is identifying the type of enrollment that fits your role.

Individual Provider: 

This applies to licensed healthcare professionals such as physicians, nurse practitioners, physician assistants, therapists, and other eligible practitioners. As an individual provider, you’ll be authorized to bill Medicare directly for covered services and to order or certify services for Medicare beneficiaries.

Institutional Provider: 

This category includes larger healthcare facilities like hospitals, skilled nursing facilities (SNFs), home health agencies, hospice centers, and other entities. These providers must meet additional compliance and certification standards as outlined by CMS.

Step-by-Step Guide To Enroll As a Medicare-approved Provider 

There are several steps that you need to follow after identifying the type of enrollment that fits with your role.

Secure Your National Provider Identifier (NPI)

Before interacting with Medicare or any other payer, you must obtain a National Provider Identifier (NPI). This unique 10-digit number is essential for various functions, including billing, verifying credentials, and communicating with payers.

• Apply via the NPPES Portal.
  
• You’ll need personal and business details, including licensing information.

Complete Your Medicare Enrollment Through PECOS

Enrolling with Medicare is your next milestone. This step allows you to bill the program and care for Medicare beneficiaries. Use the PECOS system to submit your application. Choose the correct form (CMS-855I for individual providers, CMS-855A for facilities). Attach all required documentation and validate your information.

Monitor Your Status & Stay Compliant

Once enrolled, the work isn’t over. You need to maintain your Medicare status actively. Watch for revalidation notices (every 3–5 years). Update PECOS anytime your address, tax ID, ownership, or licensure changes. Stay current with Medicare billing rules and compliance updates.

Check Patient Medicare Eligibility in Advance

Always verify that your patient is covered before you provide services. Medicare eligibility can change, especially with patients switching plans or enrolling in Medicare Advantage. There are several steps you can take to check if the patient is eligible or not.

You need to verify it through your EHR system (if integrated). You can also use the Medicare Eligibility Inquiry Tool or through your local Medicare Administrative Contractor (MAC). 

Collect and Organize Required Clinical Information

Before you bill, make sure your documentation is detailed and secure. Medicare requires detailed records for every billed service. Make sure you collect the accurate information, for example, accurate CPT/HCPCS and ICD-10 codes, you should have a signed patient consent and treatment orders, attach progress notes and medical necessity documentation. This is how you can prevent rejections and denials.

Submit Your Medicare Claims Correctly

When the services are provided and every detail gets documented, the time to claim a file starts. 

You can submit claims in two ways:

• Electronically through Medicare’s EDI (most common and fastest)
  
• Paper claims (CMS-1500 form), if you’re exempt from EDI

Track Claims and Respond to MAC Requests Quickly

After submission, your local Medicare Administrative Contractor (MAC) may follow up with questions, corrections, or documentation requests.

Stay on top of:

• Claims rejections or denials
• ADRs (Additional Documentation Requests)
• Payment adjustments or flags

Receive Payments and Perform Account Reconciliation

Once approved, Medicare payments are deposited via electronic funds transfer (EFT) into your practice’s designated bank account. Review your Medicare Remittance Advice (RA) to understand any deductions, denials, or adjustments. Follow up on unpaid or underpaid claims quickly.

Maintain Records and Be Audit-Ready

Medicare requires healthcare providers to retain comprehensive records for at least 10 years. This includes encounter notes, lab results, signed consents, and billing data. 

• Use secure, HIPAA-compliant EHR systems.
• Back up your data regularly.
• Be prepared for unannounced audits or medical reviews.

Specific Billing Challenges for Different Providers

Medicare billing can look different depending on the provider. Here’s a quick look at the challenges:

Individual Providers: 

Solo practitioners like doctors or therapists often struggle with managing patient volume and ensuring accurate billing. Missing details or coding errors can delay payments.

Group Practices: 

Billing for multiple providers in a group requires careful coordination. Each provider’s services must be correctly documented, and managing different NPIs for each specialist adds complexity.

Large Healthcare Institutions: 

Hospitals and big facilities face the challenge of handling a high volume of services and ensuring all departments follow strict billing rules. Proper documentation across the board is key to avoiding denials and audits.

Billing for Medicare Advantage Plans

Medicare Advantage Plans (Part C) have unique billing rules that differ from traditional Medicare. Key points include:

• Reimbursement Models: Vary based on the insurance carrier and services provided.
• Coordination of Benefits: Ensure proper coordination if patients have multiple coverages.
• Eligibility Verification: Use plan-specific methods to confirm coverage.
• Accurate Coding and Documentation: Correct codes are vital to avoid claim denials.

Payment and Dispute Resolution

When Medicare claims are underpaid or denied, it’s crucial to understand the dispute resolution process. Providers should carefully review the Remittance Advice (RA) to identify why a claim was denied or adjusted. If necessary, you can appeal the decision by submitting additional documentation or correcting errors through the Medicare Administrative Contractor (MAC). Timely response to denials ensures quicker resolution and smoother cash flow.

Medicare Billing for Specific Specialties

Different medical specialties, such as oncology, mental health, and cardiology, have unique Medicare billing requirements. For example,  

• Oncology: Requires detailed billing for chemotherapy and cancer treatments.
• Mental Health: Needs thorough documentation of patient evaluations and treatment plans.
• Cardiology: Involves specific codes for diagnostic tests and heart-related procedures.

Avoid These Common Medicare Billing Mistakes

Billing for Medicare can be complex, and even small mistakes can lead to denials and delayed payments. Many providers unknowingly make errors that affect their cash flow and efficiency. Here’s a list of the most common billing mistakes and how to avoid them:

• Improper Code Selection: Using the wrong CPT, HCPCS, or ICD-10 codes can lead to claim denials. Always verify that the codes match the services provided and the patient’s condition.
• Incomplete Documentation: Missing patient consent, treatment orders, or clinical notes can result in rejected claims. Ensure all necessary documentation is complete and accurate before submission.
• Failure to Verify Eligibility: Not confirming patient eligibility or coverage before providing services can lead to payment issues. Always check eligibility ahead of time using the correct tools.
• Ignoring Medicare Rules: Medicare regularly updates its billing rules. Providers must stay current with changes to avoid compliance errors. Subscribe to updates or work with billing experts.
• Delayed Claims Submission: Late submissions can lead to payment delays or denials. File claims quickly and track their status to ensure timely reimbursement.

Stay Updated on Medicare Billing Rules

Medicare regulations keep evolving; therefore, it becomes crucial to avoid compliance issues or claim denials. CMS (Centers for Medicare & Medicaid Services) regularly releases updates that affect billing procedures, documentation standards, and service coverage.

Final Thought:

Accurate Medicare billing is key to faster payments and fewer denials. You can stay compliant and protect your revenue by following the right steps, like proper enrollment, verifying eligibility, and submitting clean claims.

Need help? Partnering with a billing expert like CloudRCM can simplify the process and keep your practice running smoothly.

Struggling with Medicare Billing? We’ve Got You Covered!

Medicare billing can be complicated, but you don’t have to face it alone. Whether you’re a solo provider, in a group practice, or part of a large healthcare facility, understanding the ins and outs is essential for faster payments and fewer denials. At CloudRCM, we make the billing process simple and help you stay compliant with Medicare’s rules.

Need help? Contact us at (224) 231-6880, and let’s take the stress out of Medicare billing!

FAQs

How do I enroll with Medicare as a provider?

Apply for an NPI via NPPES, then enroll through PECOS using CMS-855I (individual) or CMS-855A (facility).

What is PECOS, and why do I need it?

PECOS is Medicare’s online enrollment system. It’s required to bill Medicare and keep your provider status active

How do I check a patient’s Medicare eligibility?

Use your EHR system, the Medicare Eligibility Inquiry Tool, or check through your MAC portal.

What are the common reasons for Medicare claim denials?

Top issues include coding errors, missing NPIs, eligibility mismatches, and incomplete documentation.

How often do I need to revalidate Medicare enrollment?

Every 3–5 years. Watch for revalidation notices in PECOS or from your MAC.