Can You Outsource Medicare Eligibility, Prior Auths, and Billing Follow-Up?
Dedicated HIPAA-trained teams run your Medicare eligibility and MBI checks, the prior authorizations Original Medicare actually requires, MAC claim follow-up, MSP questionnaires, crossover tracking, and PECOS enrollment paperwork inside your own PM system and portals. Flat weekly pricing from $299 per FTE (volume based), with a trained backup included at no charge. Live in 14 days.
The Medicare Work Your Team Does, We Staff
What Is Medicare, From the Billing Desk?
Medicare is the federal health program run by CMS for people 65 and older and for certain younger people with disabilities, and for a billing desk it behaves as two different payers wearing one name. Original Medicare, Parts A and B, is fee-for-service: claims go to a Medicare Administrative Contractor, the private company CMS pays to process claims for your jurisdiction, and national rules plus your MAC’s local coverage determinations decide what gets paid. Medicare Advantage, Part C, moves that same beneficiary into a private plan from carriers such as UnitedHealthcare, Humana, or a Blue licensee: claims go to the plan, the plan’s networks and authorization rules apply, and the MAC does not see them. Beneficiaries can switch between the two during enrollment windows, which is why the first question on the account is not whether the patient has Medicare, but which Medicare they have this year.
Eligibility and MBI Verification Before the Visit
Our specialists verify Medicare patients from the schedule: they confirm active entitlement, record the Medicare Beneficiary Identifier exactly as issued, check Part A and Part B effective dates, and flag whether the patient has moved into a Medicare Advantage plan since the last visit, so the claim that follows starts clean. The payer-side detail we absorb for you: real-time Medicare eligibility runs through CMS’s HETS eligibility channel, surfaced in your clearinghouse or your MAC’s provider portal, and it is the most reliable way to catch the two changes that quietly break claims, a replaced MBI after a compromised card and an annual-enrollment switch into or out of a Medicare Advantage plan. We re-verify Medicare patients at the start of each year for exactly that reason, the discipline behind re-verifying after annual plan switches, and when an MBI on file stops matching, our team runs the MBI lookup through your MAC portal instead of letting the rejection age. This is work we already deliver as a dedicated service today.
Medicare Advantage vs Original Medicare, Worked as Billing Context
Our teams treat the Original-versus-Advantage question as the first branch on every Medicare account, because the two route to different payers under different rules. Original Medicare claims go to your MAC under national and local coverage rules with no network to check; Medicare Advantage claims go to the private plan on the card, under that plan’s network, referral, and authorization requirements, and a claim sent up the wrong branch does not get paid, it gets returned, sometimes months later. The classic version is the denial that reads Medicare Advantage, not Original Medicare, the story behind CO-197 on Medicare Advantage accounts, and its mirror image, refiling after a retroactive MA disenrollment, when the plan unwinds and the claims belong to the MAC after all. Our specialists verify which Medicare the patient holds through our dedicated Medicare Advantage benefits verification service, record the plan and its rules on the account, and work MA denial queues that in-house desks rarely reach, the backlog described in who works the MA complex-claim backlog.
Prior Authorization Support, Where Medicare Actually Requires It
Our authorization specialists keep a current answer to the question that confuses even experienced front desks: does this Medicare patient need an authorization at all? For most services, Original Medicare does not use prior authorization, but CMS runs it as a condition of payment in defined programs: a required list of DMEPOS items, updated by CMS and expanded again in April 2026, and certain hospital outpatient department services such as blepharoplasty, rhinoplasty, botulinum toxin injections, cervical fusion with disc removal, implanted spinal neurostimulators, and facet joint interventions, submitted to the MAC before the service. Medicare Advantage is the opposite terrain: each plan sets its own authorization lists and portals, so the same procedure can be auth-free for Original Medicare and gated for the MA plan down the street, the confusion unpacked in does traditional Medicare require prior authorization now. Our team confirms the requirement during eligibility, submits through the MAC or the plan’s portal, chases the determination, and logs the tracking number where billing will find it, the same workflow behind our dedicated Medicare prior authorization service. Working those queues is administrative routing, not clinical judgment; medical decisions stay with your providers and the payer.
MSP Questionnaires and Crossover Claim Tracking
Two Medicare workflows live in the gap between the front desk and the billing office, and both are staffed on our side as standing queues. The first is Medicare Secondary Payer screening: federal MSP rules decide when Medicare pays second, for example behind an employer group health plan for a patient who is still working, and the practice is the one expected to ask the questions that establish payment order. Skipping them produces the denial explained in why Medicare denies CO-22 for working past 65. Our specialists run the MSP questionnaire as part of intake and re-verification through our dedicated MSP questionnaire service, and record the primary payer on the account before the claim goes out. The second is crossover: under the coordination-of-benefits agreement program, Medicare forwards paid claims to supplemental payers and Medicaid automatically, but automatically does not mean reliably, as any biller who has read why crossover claims fail to reach the secondary knows. We track the remittance for the crossover indicator and bill the secondary directly when the handoff fails, so the balance does not sit in patient AR by mistake.
MAC Claims, Denials, and AR Follow-Up
Our billers submit Original Medicare claims to your MAC, work the rejection and denial queues daily, and keep Medicare AR on its own cadence instead of blending it into commercial aging. The payer-side facts we build the cadence around: Medicare’s timely filing limit is 12 months from the date of service, one calendar year with narrow regulatory exceptions, and the denial for missing it is not appealable, which is why Medicare does not forgive timely filing after a staffing shortage. Medical-necessity denials, by contrast, reward disciplined appeals: redetermination requests are filed within 120 days through the MAC, the path walked in appealing a Medicare CO-50 denial in 120 days, with the LCD-versus-diagnosis groundwork covered in why Medicare denies CO-50 on medical necessity. A dedicated specialist statuses claims through the MAC portal, calls when the portal answer is not enough, files the appeals with the clock documented, and reports it to you daily in your own format, the work behind our Medicare AR calling and recovery service.
PECOS Enrollment and Revalidation Support
Medicare enrollment lives in PECOS, CMS’s online enrollment system, and it is unforgiving of neglect: most providers revalidate on a multi-year cycle set by CMS, the notice often goes to an address nobody checks, and a missed revalidation ends in deactivation, which stops payment entirely until enrollment is reestablished. The account of being deactivated over a revalidation notice nobody saw and the follow-on question of how long reactivation takes and who eats the unpaid gap are the two most expensive lessons in Medicare enrollment. Our credentialing specialists prepare and submit PECOS applications and changes, calendar every provider’s revalidation window before CMS has to ask, keep the correspondence address current so notices actually arrive, and follow each submission until the approval is confirmed in writing, the work behind our dedicated Medicare PECOS enrollment service. When you add a provider or a location, the paperwork moves without pulling your practice manager off the desk.
Put a Dedicated Specialist on Your Medicare Queues
Eligibility and MBI checks, the auths Medicare actually requires, MAC follow-up, MSP screening, crossover tracking, and PECOS paperwork, owned daily by a trained team inside your own systems. Meet us, pick the seats you need, and watch the work move before you commit to anything.
Book Your 2-Week Free TrialFlat Weekly Pricing Per Dedicated Specialist
1 to 4 dedicated payer-desk FTEs.
5 to 9 FTEs.
10+ FTEs.
45 hours of coverage for less than others charge for 40.
$399 per week works out to $8.87 per hour across 2,340 hours of coverage a year, flat. Your dedicated specialist covers a 9 hour day, Monday to Friday, a full hour more than a standard shift: the day starts by clearing what arrived after you closed, overnight portal messages, payer correspondence, and the morning eligibility batch, and it ends past your close so far less rolls into tomorrow. A trained backup steps in at no charge whenever they are out. Flat weekly fee per dedicated specialist, never a percentage of your collections, no setup fees.
Start with a 2-Week Free Trial. Month-to-month after, with no long-term contract.
- Salary + payroll taxes + benefits
- Recruiting + turnover replacement
- Training on your payers + PM system
- PM seat + equipment + PTO coverage
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Medicare Billing: Real Questions From the Desk
Does Original Medicare require prior authorization now?
For most services, no. CMS requires it in defined programs: a published list of DMEPOS items and certain hospital outpatient department services, such as blepharoplasty, botulinum toxin injections, cervical fusion with disc removal, and facet joint interventions. Medicare Advantage plans set their own, usually broader, authorization lists, so the first step is confirming which Medicare the patient has.
What is Medicare’s timely filing limit?
Twelve months, one calendar year, from the date of service. The exceptions in federal regulation are narrow, such as contractor error or retroactive entitlement, and a timely filing denial is not appealable, so the working rule is a filing cadence that leaves months of margin, not days.
Why did clean claims start rejecting after the patient got a new Medicare card?
CMS can issue a replacement MBI, for example after a compromised card, and the old number stops matching. The fix is procedural: re-verify eligibility, run an MBI lookup through your MAC portal, update the account, and resubmit. It is one of the quietest ways a Medicare account breaks.
Do we send Medicare Advantage claims to Medicare?
No. Medicare Advantage claims go to the private plan on the patient’s card, under that plan’s network and authorization rules; your MAC only processes Original Medicare. Billing the wrong branch is a common source of returned claims, which is why verification should establish which Medicare the patient holds before the visit.
Do we really have to run the MSP questionnaire on every Medicare patient?
You have to know the answer it produces. Federal Medicare Secondary Payer rules make Medicare pay second in defined situations, such as coverage through a working spouse’s employer plan, and the practice is expected to establish payment order. Skipping the questions surfaces later as CO-22 denials for patients working past 65.
Why did the crossover claim not reach the secondary payer?
Medicare forwards paid claims to supplemental payers through its coordination-of-benefits agreement program, but the handoff can fail: the supplemental plan on file is stale, the crossover indicator is missing on the remittance, or the secondary did not receive it. Watch the remittance for the crossover flag and bill the secondary directly when it is absent.
What happens if we miss a PECOS revalidation?
CMS can deactivate the enrollment, which stops Medicare payment until it is reestablished, and the gap is generally unpaid. Revalidation notices often go to an outdated correspondence address, so the protection is calendaring every provider’s revalidation window and keeping PECOS contact information current.
Can your team work inside our MAC portal and PM system?
Yes. Our specialists work under named individual logins you grant and can revoke, inside your PM system, clearinghouse, MAC portal, and plan portals. Your data stays in your systems, we report production daily, and you can review our activity in your own system.
Written By
Dan Nandan has spent 25+ years in IT consulting and healthcare BPO, was among the first in the US to build an RPO/BPO delivery network overseas, and has been featured in Computerworld. He runs the operations and the dedicated virtual teams behind the payer workflows on this page, including the Medicare prior authorization, eligibility, MSP, AR calling, and PECOS enrollment services linked above.
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Claim Your 2-Week Free TrialStaffingly, Inc. is an independent outsourcing provider. It is not affiliated with, endorsed by, or acting for the Centers for Medicare & Medicaid Services, any Medicare Administrative Contractor, or any Medicare Advantage plan, and it works inside client-owned systems and portal accounts under client-granted access. Medicare program details on this page are summarized from public CMS materials and can change; confirm current requirements with CMS or your MAC before acting on a specific claim.