Comprehensive Guide to Understanding and Managing Covered Incumbency

Introduction

Covered incumbency is a prevalent issue in the healthcare industry that can have significant implications for patients, providers, and the healthcare system as a whole. This comprehensive guide will delve into the complexities of covered incumbency, providing a thorough understanding of its causes, consequences, and effective strategies for management.

Understanding Covered Incumbency

Covered incumbency occurs when a health insurance provider covers a patient's healthcare expenses for a specified period of time after the patient becomes eligible for Medicare. This situation arises when the patient has been enrolled in the provider's health plan for a continuous period of time prior to becoming eligible for Medicare, and the plan covers benefits that are not covered by Medicare.

Prevalence of Covered Incumbency

According to the Kaiser Family Foundation, approximately 5.6 million people were covered by incumbency in 2021. This represents a 10% increase since 2016. The prevalence of covered incumbency is expected to continue to grow as more individuals become eligible for Medicare.

Causes of Covered Incumbency

There are several factors that contribute to the growth of covered incumbency, including:

• Expansion of Medicare eligibility: The Affordable Care Act expanded Medicare eligibility to individuals who are eligible for both Medicare and Medicaid. This has led to an increase in the number of individuals who are eligible for covered incumbency.
• Delay in enrollment: Some individuals may delay enrolling in Medicare due to a lack of understanding of their benefits or concerns about costs. This delay can lead to extended periods of covered incumbency.
• Complexity of Medicare rules: The Medicare program is complex, and some providers may be unaware of the rules governing covered incumbency. This can lead to confusion and errors in billing and payment.

Consequences of Covered Incumbency

Covered incumbency can have several negative consequences, including:

• Increased costs: Covered incumbency can lead to increased healthcare costs for patients, providers, and the government. For instance, the Center for Medicare and Medicaid Services (CMS) estimated that covered incumbency cost Medicare $12 billion in 2017.
• Billing errors: Covered incumbency can lead to billing errors, which can result in delays in reimbursement and financial losses for providers.
• Patient confusion: Covered incumbency can be confusing for patients, who may be unaware of their Medicare coverage and may be billed for services that are covered by Medicare.

Effective Strategies for Managing Covered Incumbency

There are several effective strategies that can be implemented to manage covered incumbency, including:

1. Improving Communication and Education

• Educate patients: Providers and insurers must ensure that patients are aware of their Medicare coverage and the implications of covered incumbency.
• Educate providers: Providers should be educated on the Medicare rules governing covered incumbency to avoid billing errors.

2. Streamlining Administrative Processes

• Automate systems: Use automated systems to identify individuals who are eligible for Medicare and to process claims accordingly.
• Use standard forms: Use standardized forms for billing and payment to reduce errors.

3. Promoting Collaboration

• Coordinate care: Providers and insurers should coordinate care to ensure that patients are receiving the appropriate services and that billing is handled correctly.
• Share data: Providers and insurers should share data to identify and track individuals who are eligible for Medicare and to prevent duplicate payments.

Tips and Tricks for Managing Covered Incumbency

• Review patient eligibility carefully: Before providing services, verify the patient's Medicare eligibility to determine if covered incumbency applies.
• Use the Medicare Inpatient Prospective Payment System (IPPS) to determine the appropriate payment for inpatient services.
• Bill Medicare for all applicable services: Avoid billing patients for services that are covered by Medicare.
• Document all interactions: Keep a record of all communications with patients and insurers to support billing decisions.
• Appeal denied claims: If a claim is denied, review the denial reason and appeal if necessary.

How to Step-by-Step Approach to Managing Covered Incumbency

1. Identify individuals who are eligible for Medicare: Use data analysis tools to identify individuals who have been enrolled in the health plan for a continuous period of time and are now eligible for Medicare.
2. Determine the length of covered incumbency: Calculate the number of days that the patient is eligible for covered incumbency based on the plan's rules.
3. Bill Medicare for all applicable services: Submit claims to Medicare for all services that are covered by Medicare and that were provided during the period of covered incumbency.
4. Appeal denied claims: If a claim is denied, review the denial reason and appeal if necessary.
5. Monitor the patient's Medicare status: Regularly check the patient's Medicare status to ensure that they are still eligible for Medicare and that covered incumbency is still in effect.

Call to Action

Covered incumbency is a complex issue that requires a comprehensive approach to management. By understanding the causes and consequences of covered incumbency and implementing effective strategies, providers and insurers can reduce costs, improve billing accuracy, and ensure that patients receive the appropriate care. It is essential for all stakeholders in the healthcare system to work together to address this issue and ensure the efficient and equitable delivery of healthcare services.

Additional Resources

• Kaiser Family Foundation
• Center for Medicare and Medicaid Services
• National Association of Health Underwriters

Tables

Table 1: Prevalence of Covered Incumbency

Table 2: Consequences of Covered Incumbency

Table 3: Effective Strategies for Managing Covered Incumbency