Medicare Insurance Billing, Coding & Compliance Masterclass

Explore Medicare enrollment periods, including the initial enrollment period around age 65 and special enrollment periods, and learn how late enrollment penalties raise Part B and Part D costs.

Explore Medicare eligibility by age, disability, or ESRD, including automatic enrollment at 65 for Social Security beneficiaries and manual enrollment for others.

Learn the two Medicare billing forms (CMS 1500 for outpatient, UB-04 for inpatient) and how DRGs and the Medicare fee schedule drive reimbursement, with emphasis on accurate coding.

Explore ICD-10, CPT, and HCPCS in Medicare claims, with examples showing how accurate coding supports proper billing and reimbursement.

Explore Medigap supplemental insurance and coordination of benefits with original Medicare to cover deductibles, co-payments, and coinsurance, ensuring accurate claims and reducing out-of-pocket costs.

Learn how Medicare coordinates with secondary payers like Medicaid, Medigap, and Tricare through automatic crossover claims that speed payments, reduce errors, and lower administrative work.

Explore how Medicare uses the coordination of benefits agreement (Coba) to automatically forward eligible claims to secondary insurers, emphasizing accurate enrollment and up to date Cobra IDs.

Master the Medicare crossover workflow that automatically transfers remaining balances to secondary payers via EDI. Recognize HIPAA compliant systems, timelines, and common errors.

Providers verify the Medicare crossover by reviewing the remittance advice for Ma 18 and confirming the secondary payer and Coba ID in the Mac portal, preventing unnecessary resubmissions.

Identify why Medicare crossover claims fail, verify Cobra ID in the MCC portal, and resubmit or appeal with timely filing proof to ensure secondary payer payment and reduce denials.

Discover how the Medicare crossover process speeds reimbursement and reduces patient out-of-pocket costs by routing claims to secondary payers like Medigap or Medicaid, improving revenue cycle performance.

Explore Medicare audits and compliance to ensure accurate billing and proper use of funds. RAC and MAC audits identify overpayments and enforce billing standards, while internal audits build trust.

Explore Medicare innovations, including telehealth expansion, value-based care, and digital tools, with reforms like drug price negotiation, expanded dental, vision, and hearing benefits, and emphasis on preventive care.

Explore Medicare's role across the revenue cycle, from registration and verification to coding and reimbursement, and apply strategies for parts a through d, the fee schedule, denials, and timely filing.

Explore real-world case studies on Medicare billing, including denials from incorrect CPT codes and invalid Medicare IDs. Learn to meet the 12-month timely filing rule with audits and billing software.

Explore the Medicare regulatory framework, including CMS, OIG, and MACs, and key laws like the False Claims Act, Anti-kickback statute, and Stark Law, with emphasis on proactive training and auditing.

Explore how Medicare payment integrity combines data analytics, internal audits, and staff education to detect fraud and reduce overpayments, guided by the payment error prevention program (Pep) and OIG collaboration.

Master the Medicare RAC program and the five levels of appeals—redetermination, reconsideration, ALJ hearing, appeals council, and federal court—through proactive preparation and accurate documentation.

Understand how the Medicare fee schedule uses relative value units (rvus)—work, practice expense, and malpractice—and the geographic practice cost index and conversion factor to determine payments.

Medicare shifts from fee-for-service to value-based care, rewarding quality and cost efficiency through MIPs, APMs, and collaborative models like ACOs, with emphasis on preventive care and reduced readmissions.

Explore bundled payments in Medicare, including the BPCI initiative, their advantages and challenges within value-based care, and how four PCI models align costs with outcomes to improve care quality.

Navigate NCCI edits and apply modifiers to prevent improper coding and denials in Medicare claims, and master chronic care management and telehealth billing with proper time-based codes and documentation.

Master Medicare billing by reducing denials and claims rejections through front end verification, audits, coding accuracy, and denial management software that tracks trends and KPIs.

Identify primary and secondary payers and coordinate benefits using the CMS COB system, applying MSP codes to ensure accurate, timely Medicare claims and reduce denials.

Compare Medicare Advantage and original Medicare within revenue cycle management, highlighting claims submission differences, prior authorization, denials, and the role of verification and technology to improve reimbursement.

Optimize Medicare cash flow by ensuring timely filing within 12 months of service, accurate documentation and coding, proactive follow-up, and leveraging claim scrubbers, analytics, and Medicare portals.

Explore how Medicare data informs financial forecasting and revenue management, track KPIs like denial rate, first pass resolution rate, and days in accounts receivable to optimize the revenue cycle.

Medicare supports population health by addressing aging needs and chronic disease management through preventive services, screenings, vaccinations, and wellness visits. Telehealth and care coordination improve access and reduce readmissions.

Telehealth expanded under Medicare during the pandemic; reimbursement challenges remain; providers must code correctly with telehealth CPT codes and POS; ensure HIPAA-compliant platforms and patient consent.

Explore how AI and robotic process automation enhance fraud detection, predictive analytics, and operational efficiency in Medicare while addressing regulatory considerations like HIPAA, CMS approvals, and ethical AI practices.

Navigate complex Medicare billing scenarios by mastering multi-layered claims, overlapping coverage, and dual eligibility, while ensuring compliant, timely reimbursement through precise documentation and payer coordination.