How to Bill Medicare for Services: A Comprehensive Guide for Health Tech Startups

In today's rapidly evolving healthcare landscape, startups and treatment centers are often seeking ways to navigate the complex world of healthcare billing while ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA). This federal law, enacted as part of the Affordable Care Act (ACA), establishes stringent regulations to protect patients' privacy and security. Navigating the intricacies of HIPAA compliance is essential for any healthcare software or cloud-based healthcare platform, and this includes digital health tools and solutions designed to improve patient care and streamline reimbursement processes.

Headless Electronic Health Record (EHR) platforms like Oystehr provide a practical means to embed workflows for Medicare and Medicaid submissions.  Oystehr offers a FHIR-compliant data store and the APIs to submit and manage claims.  Headless APIs better support the custom, often lightweight, workflows needed in a health tech startup than billing modules of monolithic EHRs. This article aims to help startups interested in Medicare qualify for reimbursement.

Medicare had traditionally offered two routes for claim submission: paper and electronic. Paper claim submission turnaround was always much slower than electronic submission.   Now, as a result of the Administrative Simplification Compliance Act, Medicare will only accept electronic claim submission in most cases. Here, cloud-based healthcare platforms and healthcare software, such as Oystehr, come into play, offering streamlined solutions for managing claims efficiently.

In this digital age, healthcare is increasingly embracing digital health solutions. Startups in the healthcare sector are harnessing the power of headless EHR platforms like Oystehr to embed digital health tools and solutions into their workflows. With the focus on adaptability and programmability, these solutions facilitate lightweight revenue cycle management (RCM) for healthcare facilities and health tech startups.

For both healthcare startups and healthcare facilities, the quickest path to reimbursable services is often Medicare and Medicaid.  Not only do they represent a huge percentage of the overall patient population in the US, but the path to approved claim submission is more clearly documented than negotiations with private payers.  However, “more clearly documented” doesn’t mean “easy to understand and implement.” Here's our comprehensive guide on the Medicare billing process and how your business can streamline submission for healthcare services.  

Let’s take a look at how to set up electronic submission.

1. Getting started with Medicare

Medicare billing is done by provider or practice group.  This means you will either register your startup with Medicare as a practice group (if the startup has clinicians providing services) or the users of your application will need to register, if they haven’t already.

First, you enroll in Medicare payment participation. Every provider who bills Medicare will need an NPI number. The application process for NPI assignment occurs via the National Plan and Provider Enumeration System (NPPES), linked here. NPI assignment is granted to a wide variety of healthcare provider types. Remember, you can always verify an NPI number by using the registry managed by NPPES. 

Upon assignment of an NPI, you need to complete Medicare’s separate enrollment application. This form is managed via the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and requires an account. Once enrolled in PECOS a provider is considered registered with Centers for Medicare and Medicaid Services (CMS). 

Finally, you need to locate your Medicare Assigned Contracter (MAC). The MAC is assigned regionally as a fee-for-service contractor who will process your application for Medicare billing as well as handle any specific issues that may arise during the process. Medicare maintains a contact list for all MACs, the current version of which can be found on this PDF. 

If you have completed this process and received confirmation from your MAC of successful enrollment, you are now a Medicare provider. 

Fig. 1: Medicare Provider Enrollment Process. Credit: CMS.GOV

2. Going paper-free…

Once you are authorized to bill Medicare you will need to submit your claims electronically. This is done via Electronic Data Interchange (EDI) and requires - you guessed it - another enrollment process. Any provider billing Medicare must complete the EDI and agree to its terms, however a single EDI may be executed on behalf of an organization if the billing group elects. The EDI ensures safe, efficient, and secure data submission to Medicare by a billing party or clearinghouse. It is effectively an assumption of liability under CMS rules and HIPAA.

You may obtain a copy of the CMS Standard EDI Enrollment form from your regional MAC. 

Any organization billing to Medicare must also send notice to their regional MAC of its intent to submit claims and identify which type of Medicare service is offered (e.g.: Part A, B, or DME). The billing party must submit a CMS Form 10164 directly to their MAC with this notification. A copy of the 10164 instructions can be found here. This step is critical, as it also identifies which parties will be processing the claims for the provider - including data stores and clearinghouses. The Oystehr team is experienced with working through this process and is ready to assist with your questions.

Fig 2.: Common Enrollment Delays. Credit: CMS.GOV

3. Getting paid

After completion of all EDI and MAC notification requirements, the only step remaining is completing the Medicare EFT enrollment process. This enables a full-circuit of payment back from Medicare to the account of your choice. EFT enrollment is optional, but avoids paper checks and delays in processing. EFT Enrollment is straightforward and generally handled by cooperation between the provider and their MAC. 

Upon completion of sections I-III a provider can bill Medicare and receive payment electronically.

Fig. 3: The Medical Billing Cycle. Credit: ENTER.HEALTH

4. How headless EHRs make this simpler

Let’s suppose that you want to streamline your electronic claims, but don't have the resources for a large and bulky EHR billing module. Headless products like Oystehr shine as adaptive, codeable solutions for lightweight RCM. Via APIs to health information exchanges, Oystehr is able to receive your billing data and send it on to an HIE/MAC automatically.  Oystehr will take the reins of billing Medicare and provide you with ongoing submission status reports so you know where and when your revenue is processed. 

Oystehr electronic claim management setup is simple with the help of our dedicated team of specialists. All you need is a de-identified sample of a standard CMS-1500 professional fee claim form. Our existing code samples can be modified to support any specific fields or addendums to coding from your practice, and the headless nature of Oystehr enables your technical team to take on the programmability and automation of functions to suit any use case. 

Easily monitor the status of your revenue cycle with Oystehr's data stores. You can create intuitive displays to suit your specific use-cases.

If you are interested in learning more about how Oystehr can empower your electronic claim submission processes, schedule a meeting with us today. Our team includes technical and subject matter experts who will help you to develop a custom application solution for your specific practice goals.

Frequently Asked Questions:

1. What are the advantages of using headless EHR platforms like Oystehr for Medicare billing?‍
   • Headless EHR platforms offer flexibility and adaptability, allowing startups and healthcare facilities to streamline their revenue cycle management processes. With Oystehr, users can embed digital health tools and solutions into their workflows, ensuring efficient electronic claim submission and ongoing monitoring of revenue processing.

1. Is Medicare enrollment necessary for startups offering healthcare services or solutions?
   • Yes, Medicare enrollment is essential for any provider or practice group looking to bill Medicare for reimbursable services. Startups must obtain an NPI (National Provider Identifier) number, complete Medicare's enrollment application via the PECOS system, and identify their Medicare Assigned Contractor (MAC) for claims processing.
2. What steps are involved in setting up electronic claim submission for Medicare billing?
   • Setting up electronic claim submission for Medicare billing involves several steps, including completing the Electronic Data Interchange (EDI) enrollment process, notifying the regional MAC of intent to submit claims, and enrolling in Medicare's Electronic Funds Transfer (EFT) system for electronic payments.
3. How does Oystehr simplify the electronic claim management process for Medicare billing?
   • Oystehr simplifies electronic claim management by offering a headless EHR platform with FHIR-compliant data storage and APIs for seamless integration with healthcare systems. With Oystehr, users can automate claim submission, receive ongoing status reports, and customize billing processes to suit their specific needs.
4. Can Oystehr accommodate specific billing requirements or addendums for Medicare claims?
   • Yes, Oystehr's headless nature allows for easy customization and automation of billing functions to accommodate specific requirements or addendums for Medicare claims. Users can modify existing code samples or develop custom solutions tailored to their practice goals.

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