Medicare Reimbursement
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Andrew Wheeler
Vice President of Federal Advocacy and Finance
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Medicare Guidance for Missouri Hospitals
Hospitals that serve as Medicare providers must adhere to strict regulations and guidelines to ensure compliance and receive proper reimbursement. Understanding these requirements is essential for maximizing reimbursement, avoiding penalties and ensuring financial stability while delivering high-quality patient care.
MHA provides guidance and resources to help hospitals navigate Medicare reimbursement policies, optimize billing practices and maintain compliance with federal regulations.
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Key Medicare Reimbursement Requirements
To ensure timely and accurate reimbursement, hospitals should follow up-to-date guidelines from the Centers for Medicare & Medicaid Services:
- Adhere to Medicare Conditions of Participation – Federal regulations that define the standards hospitals must meet to participate in Medicare
- Ensure accurate coding and documentation – Proper ICD-10 and CPT coding is critical for claims processing and reimbursement accuracy
- Stay updated on payment model changes – Medicare reimbursement policies evolve, including shifts toward value-based payment models
- Comply with Medicare billing and appeals processes – Understanding the process for submitting claims and appealing denied reimbursements can prevent revenue loss
- Monitor quality reporting requirements – Hospitals must meet quality benchmarks under programs like the Hospital Value-Based Purchasing Program to maximize reimbursement
If you believe your hospital has been unduly denied for reimbursement by CMS, you can submit a claim, appeal or complaint by using their website.
For more information, health care providers can access guidance for handling Medicare claims, processing, provider enrollment, billing support and compliance through the Wisconsin Physicians Service Government Health Administrators site.
Resources on Medicare Regulations
Understanding Final PPS Regulations
Each year, the Centers for Medicare & Medicaid Services updates regulations for Medicare’s Prospective Payment System, impacting hospital reimbursement rates and payment policies. To help hospitals navigate these changes, MHA provides issue briefs summarizing key updates, compliance requirements and financial implications for Missouri hospitals. Below are the latest briefs on fiscal year 2019 PPS regulations for the following care providers:
Medicare Enrollment & Compliance for Hospitals & Critical Access Hospitals
Hospitals and Critical Access Hospitals must meet CMS enrollment and compliance requirements to participate in Medicare and receive reimbursement. These guidelines ensure that facilities adhere to federal standards for patient care, billing and operational practices.
- Hospital Enrollment & Compliance – CMS provides eligibility, enrollment, and compliance guidelines for hospitals participating in Medicare, ensuring they meet federal regulatory standards for reimbursement and patient care.
- Critical Access Hospital Enrollment & Compliance – CMS establishes specific requirements for CAHs, including eligibility criteria, certification standards, and operational guidelines to maintain Medicare participation and payment eligibility.
Advocates for Medicare Improvements: Medicare Payment Advisory Commission
For more information on Medicare payment issues and policy advice, use the Medicare Payment Advisory Commission’s online library. Their reports evaluate payment systems, access and quality of care, and overall program efficiency to inform providers and drive improvements.