Medicare Provider Alert: Your Responsibility When Using Outsourcers

Published 07/18/2024

As a reminder, the Centers for Medicare & Medicaid Services (CMS) requires providers, billing companies, and outsourced agencies to use the Interactive Voice Response (IVR) system or the Palmetto GBA eServices tool to verify eligibility and claim status. An increase in these inquiries from billing companies and outsourced agencies has been noted where some are failing and/or refusing to use the IVR or Palmetto GBA eServices. Additionally, some of these individuals are not familiar with basic Medicare coverage or billing requirements and explanations and guidance must be repeated on every call.

If you use a billing company or an outsourced agency to perform any of your Medicare work, please remember these companies are representing your practice. When the PCC recognizes a pattern of calls where a vendor is not using the IVR or eServices for eligibility or claim status, Palmetto GBA may contact the billing provider to discuss their vendor’s activities that are unnecessarily and incorrectly tying up the PCC phone lines. The pattern we recognize most is questions that don’t pertain to the providers actual claim but instead are generic scripted questions that are asked over and over with the same exact response each time, and questions that can easily be answered by reviewing the Remittance Advice, using our Portal, the IVR and/or our website.

You can help us by making sure that you are providing your vendor with access to the Medicare remittance and appeal notices for services and claims they will be working on and that your vendors:

  • Have knowledgeable staff
  • Are aware of and following Medicare rules and regulations and are using resources available on the Palmetto GBA and CMS websites and
  • Understand the requirement and will or are using the available IVR and eServices tools to verify eligibility and claims status

Providers are also cautioned to remember that the responsibility to guard Medicare beneficiary Protected Health Information (PHI) lies with the provider and not with the outsourcing agency or billing company. So, if a PHI disclosure were to occur, the provider would be held liable for any financial penalties related to that disclosure. It is important that you verify adequate processes are in place to ensure PHI is protected.

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