Article Detail - JD DME

Medicare Open Enrollment season is a key period for beneficiaries to review and adjust their healthcare coverage for the upcoming year. For healthcare providers, this time of year presents an important opportunity—and responsibility—to ensure they are accurately billing Medicare and the appropriate payor after January 1, 2025, when Open Enrollment changes take effect.

During this period, Medicare beneficiaries may switch between Original Medicare, Medicare Advantage (Part C), and Medicare Prescription Drug Plans (Part D). These changes can impact how and where claims are submitted, and it’s critical for suppliers to ensure they have up-to-date information about their beneficiary’s insurance coverage to avoid billing errors, claim denials, and compliance issues.

What is Medicare Open Enrollment?

Medicare Open Enrollment occurs annually from October 15 to December 7 and allows beneficiaries to make changes to their Medicare coverage. These changes will be effective on January 1, 2025, and can include:

• Switching from Original Medicare (Parts A & B) to a Medicare Advantage Plan (Part C)
• Switching from one Medicare Advantage Plan (Part C) to another
• Changing from one Medicare Prescription Drug Plan (Part D) to another
• Switching from Medicare Advantage back to Original Medicare
• Joining or dropping a Medicare Part D plan

For healthcare providers, it’s essential to know that any changes in a beneficiary’s coverage, especially a switch to or from a Medicare Advantage Plan, will affect how services are billed and who is responsible for payment.

Suppliers should review the following prior to billing any services with dates of service on or after January 1, 2025:

• Medicare ID cards, which may have changed if a beneficiary switched plans.
• Beneficiary eligibility and benefits through the Noridian Medicare Portal (NMP)

Update Insurance Information in Your System

Once Open Enrollment ends, make sure to update your beneficiary’s insurance information in your system. Suppliers should check the following:

• Beneficiary Insurance Information: Medicare beneficiaries will often receive new Medicare cards if they change from Original Medicare to Medicare Advantage, or if their plan's details (like a plan number) change. Ensure that this updated information is recorded.
• Verify Network Participation: If a beneficiary has switched to a Medicare Advantage Plan, confirm whether the new plan’s network covers the services provided.
• Check Coverage Dates: The new plan will take effect on January 1, 2025, so suppliers need to ensure that services rendered on or after this date are billed to the correct payor.

Understand the Billing Process for Medicare Advantage Plans

If your beneficiary switches to, or from a Medicare Advantage (Part C) plan, the billing process will change. Unlike Original Medicare (Parts A and B), Medicare Advantage plans are administered by private insurers. When billing a Medicare Advantage plan, the supplier must follow the specific guidelines set by the insurance company, which may differ from the traditional Medicare process.

• Medicare Advantage Claim Submission: Claims for services rendered to beneficiaries with Medicare Advantage coverage should be submitted directly to the Medicare Advantage insurer, not to Medicare. Each Medicare Advantage plan has its own claims submission process, so be sure to familiarize yourself with each plan's requirements.
• Out-of-Pocket Costs: Medicare Advantage plans typically have different cost-sharing structures than Original Medicare. i.e., copays and deductible.

Educate Staff on Changes to Billing Procedures

It is important to inform and train your billing staff about any changes in Medicare coverage for your beneficiaries after January 1, 2025. Billing teams need to be well-versed in the following:

• New Payor Information: Whether your beneficiaries are switching from Original Medicare to a Medicare Advantage plan, your billing team must know the correct payor and how to submit claims for each beneficiary.
• Claim Denials: Be prepared to manage claim denials that may arise due to incorrect payor information or issues with plan eligibility. When a claim is denied, investigate whether the beneficiary’s plan changed after Open Enrollment and re-submit to the correct insurer.
• Medicare vs. Medicare Advantage: Ensure that all claims for Original Medicare beneficiaries are submitted to Medicare, while claims for Medicare Advantage beneficiaries go to the private insurer administering the plan.

Monitor Claims Processing Closely

In the first few months of 2025, there may be delays or errors in claims processing as insurers update their systems and transition beneficiaries into new plans. Suppliers should closely monitor all claims to ensure they are being processed by the correct insurer:

• Re-submit Claims if Necessary: If a claim is denied or rejected due to incorrect insurance information, be prepared to re-submit it to the correct payor.
• Follow Up on Unpaid Claims: If you notice that claims are being paid incorrectly, or not at all, take immediate steps to follow up with the insurer.