Buying a Medicare book of business?

[Packerland]

I have a guy I work with made the mistake of saying, “if you buy a plan G, you only owe the Part B deductible and then you pay $0 the rest of the year.”
His client went to Mayo in Jax for blood work. She owed $900. I told him to never say everything is covered but to tell them that it’s covered when it’s Medicare approved charges.

$900. Plan G. Mayo. This was after Medicare paid and the Supp, and she was livid. He forgot that Medicare doesn’t cover annual physicals. And I guess they charge through the nose.

We tell our agents to inform their client to always ask if the procedure is a Medicare Approved expense and if it is the supplement will pay their portion. We also caution the clients with with a med supplement to make sure that there facility or physician accepts Medicare assignment.

 

[rmhaire]

$900. Plan G. Mayo. This was after Medicare paid and the Supp, and she was livid. He forgot that Medicare doesn’t cover annual physicals. And I guess they charge through the nose.

In facility blood work is not an annual physical and should have been covered if requested by her doctor. Even excess charges would be covered since she has a plan G.

Quite possible it was a coding error.

 

[somarco]

In facility blood work is not an annual physical and should have been covered if requested by her doctor. Even excess charges would be covered since she has a plan G.

Quite possible it was a coding error.

Could also be the provider failed to provide the ABN form, in which case, the patient is not responsible for the denied charges.

Diagnostic laboratory tests
Medicare Part B (Medical Insurance) covers medically necessary clinical diagnostic laboratory tests, when your doctor or provider orders them. These tests may include certain blood tests, urinalysis, certain tests on tissue specimens, and some screening tests.

Your costs in Original Medicare
You usually pay nothing for Medicare-covered clinical diagnostic laboratory tests.


What it is
Diagnostic laboratory tests look for changes in your health and help your doctor diagnose or rule out a suspected illness or condition.

https://www.medicare.gov/coverage/diagnostic-laboratory-tests

If you have Original Medicare, your doctor, other health care provider, or supplier may give you a written notice if they think Medicare won’t pay for the items or services you’ll get. This notice is called an “Advance Beneficiary Notice of Non-coverage,” or ABN. The ABN lists the items or services that your doctor or health care provider expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.

What can I do if I get this notice?
On the ABN, you’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

Option 1: You want items or services that Medicare may not pay for. Your provider or supplier may ask you to pay for these items or services now, but you also want your provider or supplier to submit a claim to Medicare.

If Medicare denies payment: You’re responsible for paying. However, since a claim was submitted, you can appeal to Medicare.

If Medicare does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).

Option 2: You want items or services that Medicare may not pay for, but you don’t want your provider or supplier to submit a claim to Medicare. You may be asked to pay for the items or services now. Because you asked your provider or supplier not to submit a claim to Medicare, you can’t file an appeal.

Option 3: You don’t want the items or services that Medicare may not pay for, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.
Get details about filing an appeal.

Remember, an ABN isn't an official denial of coverage by Medicare. You have the right to file an appeal if a claim is submitted and Medicare denies payment. Your ABN has clear directions for getting an official decision about payment from Medicare, and for filing an appeal if Medicare won’t pay.
https://www.medicare.gov/basics/your-medicare-rights/your-protections

Review the ABN linked below. Any claim that your provider believes may not be covered by Medicare needs to give you the COMPLETED form including the name of the test/procedure, appropriate code and the estimated cost of the test/procedure if the claim is denied by Medicare.

https://www.ambrygen.com/file/material/view/1436/ABNEnglish2023v508 current.pdf

 

[MedicareAgent]

what does this have to do with buying a book of business?

 

[rmhaire]

what does this have to do with buying a book of business?

Nothing. We figured that you'd bought it by now.

 

[goillini52]

Could also be the provider failed to provide the ABN form, in which case, the patient is not responsible for the denied charges.

Diagnostic laboratory tests
Medicare Part B (Medical Insurance) covers medically necessary clinical diagnostic laboratory tests, when your doctor or provider orders them. These tests may include certain blood tests, urinalysis, certain tests on tissue specimens, and some screening tests.

Your costs in Original Medicare
You usually pay nothing for Medicare-covered clinical diagnostic laboratory tests.


What it is
Diagnostic laboratory tests look for changes in your health and help your doctor diagnose or rule out a suspected illness or condition.

https://www.medicare.gov/coverage/diagnostic-laboratory-tests

If you have Original Medicare, your doctor, other health care provider, or supplier may give you a written notice if they think Medicare won’t pay for the items or services you’ll get. This notice is called an “Advance Beneficiary Notice of Non-coverage,” or ABN. The ABN lists the items or services that your doctor or health care provider expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.

What can I do if I get this notice?
On the ABN, you’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

Option 1: You want items or services that Medicare may not pay for. Your provider or supplier may ask you to pay for these items or services now, but you also want your provider or supplier to submit a claim to Medicare.

If Medicare denies payment: You’re responsible for paying. However, since a claim was submitted, you can appeal to Medicare.

If Medicare does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).

Option 2: You want items or services that Medicare may not pay for, but you don’t want your provider or supplier to submit a claim to Medicare. You may be asked to pay for the items or services now. Because you asked your provider or supplier not to submit a claim to Medicare, you can’t file an appeal.

Option 3: You don’t want the items or services that Medicare may not pay for, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.
Get details about filing an appeal.

Remember, an ABN isn't an official denial of coverage by Medicare. You have the right to file an appeal if a claim is submitted and Medicare denies payment. Your ABN has clear directions for getting an official decision about payment from Medicare, and for filing an appeal if Medicare won’t pay.
https://www.medicare.gov/basics/your-medicare-rights/your-protections

Review the ABN linked below. Any claim that your provider believes may not be covered by Medicare needs to give you the COMPLETED form including the name of the test/procedure, appropriate code and the estimated cost of the test/procedure if the claim is denied by Medicare.

https://www.ambrygen.com/file/material/view/1436/ABNEnglish2023v508 current.pdf

I was presented an ABN on some blood tests and I declined the tests. I said something to the doc, and he resubmitted with the proper codes to show medically necessary and it went through.

 

[somarco]

I was presented an ABN on some blood tests and I declined the tests. I said something to the doc, and he resubmitted with the proper codes to show medically necessary and it went through.

Regardless of the type of coverage you have, no one is looking out for you. If you want to win the battle you have to fight.

 

[jeff.j.miller]

Actually it’s video from sept . Christian brindle who’s bought many books and just sold to integrity. Start at min 3:30

I feel so dumb after listening to this guy. I am just a dum agent with 185 Medicare and 185 ACA clients and a few groups- these guys have 50 times my business and seem fine, I am struggling to keep my head above water!! I appreciate the link, DonP.

 

[hockeyday]

I feel so dumb after listening to this guy. I am just a dum agent with 185 Medicare and 185 ACA clients and a few groups- these guys have 50 times my business and seem fine, I am struggling to keep my head above water!! I appreciate the link, DonP.

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