THRIVE in 2025!
Updates and recommendations for the
New Year!
Sound Medical Billing Solutions can help you THRIVE in 2025!
Medicare Deductible and Therapy Cap Thresholds
2025 Medicare Deductible: $ 257.00 (+$ 17.00)
2025 Medicare Therapy Cap: $ 2,410.00 (+$ 80.00)
Targeted Medical Review: $ 3,000.00 (no change)
New Year - New Insurance Verification
Today's medical insurance environment sees many patients changing insurance plans with the start of the new year. Additionally, many patient's that retain their insurance provider may see new policy requirements that take effect on January 1, 2025. To best serve your patients and avoid unnecessary claims denials , SMBS suggests the following office staff procedures:
Request each patient present all insurance cards (primary/secondary/tertiary)
Verify all insurance information on file with what is presented
is the insurance carrier different?
is the ID# different?
is the guarantor different?
Verify the benefits with each payer to determine the following:
is the patient covered under this policy?
what is the patient financial responsibility (co-payment, co-insurance, deductible)? (amounts may change in the new year)
what are the pre-authorization requirements and will previous authorizations carry-over for the new year
Perform a new EVAL when a new insurance becomes active
Complete a new intake form to document all insurance changes so that a new account can be created
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Strategies to Thrive in 2025
Proven strategies to raise revenue and secure compliance in 2025:
- Review office procedures to ensure accurate document acquisition and insurance verification
           - Create an effective front office to billing workflow that ensures valid claims
- Ask patients to confirm their insurance at each visit or after a brief hiatus of treatment
           - Collect patient balances at the time of service
note: many supplemental plans do not pay the primary deductible and may require a co-payment, co-insurance, or deductible
- Eliminate courtesy forgiveness of patient balances
note: courtesy forgiveness of patient financial responsibilities can be considered a violation of contractual obligations
           - Review network status credentialing to ensure PPO reductions are eliminated
- Author comprehensive defensible documentation that meets Medicare guidelines
- Analyze billing vs treatment and documentation to ensure your practice is following the 8-minute rule
- Develop alternative revenue sources
Medicare Advantage Programs
The name is confusing patients and providers alike. Medicare Advantage Plans are third party commercial insurance plans that are marketed to the Medicare eligible population and are NOT a government health plan. For the provider, Medicare Advantage Plans often require
pre-authorization and network credentialing. For the patient, Medicare Advantage Plans often carry higher out of pocket expenses in the form of co-payments, co-insurances and deductibles. When asked, patients will often believe they have Medicare and may present a Medicare identification card along with a Medicare Advantage identification card.
Note: all Medicare eligible patients possess a Medicare identification card; however, this does not ensure enrollment in the government health plan.
Steps to help navigate confusion regarding Medicare Advantage Plans ensuring you will be paid:
1- identify patients with a Medicare Advantage Plan and/or changes to a patient's supplemental insurance
note: verification of benefits with Medicare will help identify patients enrolled in a Medicare Advantage Plan
2- identify the differences of the enrolled Medicare Advantage Plan to the assumed enrollment in Medicare
3- communicate patient financial responsibility and have patients sign a benefits estimate
4- collect all patient financial responsibilities at the time of service
5- acquire all necessary pre-authorizations prior to service
For additional details regarding 2025 governance or for guidance on your practice needs,
contact SMBS for a personal practice review and consultation.
We at SMBS wish you a happy, healthy, and profitable 2025!
Give us a call and we can help you THRIVE in 2025!
Let us provide your SOUND MEDICAL BILLING SOLUTIONS!
John Spiezio, President
Sound Medical Billing Solutions, LLC
The Outpatient Rehabilitation Practice Management and Billing Specialists!
Call, click, or email for more information about this or any other topic that my affect your practice. We will be happy to help!
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