Navigating the complexities of Medicare billing can be challenging for healthcare providers. Among the various billing procedures, split-claim billing stands out as a specialized process that requires careful attention to detail to ensure compliance and maximize reimbursements. This guide aims to clarify what split-claim billing entails, how it functions within the Medicare system, and how providers can streamline their processes using innovative solutions.
Understanding the fundamentals of split-claim billing is essential for providers managing diverse services and reimbursement models. It involves separating different types of charges—such as professional and technical fees—into distinct claims. This separation is crucial because Medicare often reimburses these components differently, depending on the service location and provider type. For example, hospitals and Rural Health Clinics (RHCs) typically bill outpatient services on specific claim forms like the UB-04, whereas outpatient clinics commonly use the CMS 1500 form for Part B claims.
Most claims consist of two primary charge categories:
- Professional charges: fees for physician services.
- Technical charges: costs associated with facility overhead, medical supplies, medications, nursing staff, and support personnel.
Hospitals and RHCs generally bill these charges separately, which can introduce complexity but also offers opportunities for optimized reimbursement. Usually, hospitals and Rural Health Clinics submit their charges to Part A Medicare using a UB-04 form, while outpatient clinics bill Part B using a CMS 1500 form. The majority of claims are processed electronically, streamlining the billing workflow and reducing errors. However, exceptions to these practices do exist, especially when services involve both facility and professional components, necessitating split-claim procedures.
RHC Split Claim Scenario
Rural Health Clinics are subject to specific rules when billing for services that fall outside the traditional RHC reimbursement model. Medicare has identified a list of “non-RHC services” that, although covered, must be billed separately. These include laboratory tests, radiology procedures like X-rays and EKGs (technical only), hospital and ambulance services, external braces, prosthetic devices, hospice care related to certain conditions, and durable medical equipment.
Freestanding RHCs typically bill professional charges to Medicare Part A via the UB-04 form, while technical services such as labs are billed on a CMS 1500 form to Part B. Provider-based RHCs, on the other hand, bill professional charges using a UB-04 and technical components on a UB-04 under their parent provider. This separation ensures accurate reimbursement and compliance with Medicare regulations.
Tips for Improving Practice Reimbursements
To enhance revenue cycle management, practices should regularly evaluate their billing practices. Key questions include: Are patient co-pays consistently collected? Are payments received promptly? What percentage of claims are rejected? Implementing a reliable monthly reconciliation process can significantly improve cash flow. For additional strategies, consider exploring how to optimize your collection efforts by reviewing best practices in healthcare billing.
How to Bill Medicare Split Claims
Billing both UB-04 and CMS 1500 forms can be challenging, especially since many billing systems are designed to handle only one type of claim at a time. This limitation often forces providers to adopt additional software or manual processes, which can lead to inefficiencies, higher collection costs, and potential revenue loss. Even systems capable of managing both forms may not support seamless split-claim processing, requiring multiple steps to correct and rebill claims.
The manual nature of split-claim billing often results in frustration and delays—something many providers experience firsthand. To address these issues, innovative solutions have emerged that automate and simplify the process.
A Better Approach – RHC Split-Claim Billing with Azalea
Founded on extensive experience in medical billing, Azalea has developed a robust solution to streamline split-claim billing. This platform enables users to automate the division of claims using preset rules, significantly reducing errors and saving staff time. By automating these processes, practices can improve accuracy and efficiency, ensuring faster reimbursements and fewer rejected claims.
What Is Automated Split-Claim Billing?
Azalea’s automation engine allows billing teams to set rules that automatically split claims based on predetermined criteria. This reduces manual intervention, minimizes mistakes, and enhances overall billing quality. To see this technology in action, visit our Automated Split Billing Blog or request a demo for a live demonstration.
Given that many electronic health records (EHRs) and practice management systems (PMs) focus on either hospital or outpatient billing, handling both in a single claim can be complex. When systems lack robust split-claim capabilities, errors can increase, and operational efficiency suffers. For instance, US San Diego Health reported that after adopting advanced billing solutions, their claim accuracy improved, and coding productivity soared—reducing colonoscopy coding time from over 12 minutes to less than five.
If your current billing process feels outdated or inefficient, consulting with experts can help you modernize your approach. Implementing advanced software solutions tailored for split-claim billing can make a significant difference in your revenue cycle. Discover more about how modern billing technology is transforming healthcare by exploring innovative healthcare applications.
Effective split-claim billing is critical for maximizing reimbursements within the Medicare system. By understanding the process, leveraging automation, and consulting industry experts, healthcare providers can improve accuracy, reduce administrative burdens, and enhance their financial health.