Dr. Refuses to File Medicare Claim

Jan 11, 2016

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  1. insuranceconceptscindy
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    insuranceconceptscindy Guru

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    One of my clients sees a cash-only concierge doctor. Client has Medicare and F. All last year he had paid provider in cash, provider did not bill Medicare at all. For grins and giggles, I looked up the provider on Medicare.gov- it says he takes assignment.
    Client filled out and mailed in a claim form with all of the details. Meridian sent back a letter saying, as of 1990, the provider is required to sign up with Medicare and bill them. If doc refuses to bill, fill our form, etc.

    Of course, I asked the client if maybe he should think about changing doctors- he said no. He would be prepared to deal with the hassle to keep doc.:no:

    Anyone run into this? You would think that if doc went cash-only, they would update Medicare of their status. I don't want the provider to get into any trouble if we say they refused to bill.

    Thoughts?
     
  2. goillini52
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    goillini52 MAGA...Eat More Bacon & BUILD THAT WALL!!!

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    "If you have to pay up front for your appointment because your provider refuses to bill Medicare, you should take action. A refusal to bill Medicare at your expense is often considered to be Medicare fraud and should be reported. You can report the problem to
    •the administrators at the place where your doctor or medical equipment supplier works;


    •your Medicare Part B carrier;
    •Medicare Administrative Contractors (MACs)"

    .........


    "If your provider continues to refuse to bill Medicare or is unable to do so, you may file a Medicare claim yourself as a last resort. Submit a Patient's Request for Medicare Payment form (also called the CMS-1490S form) to your Medicare Part B carrier. You must send bills or receipts for the service along with the form. Claims submitted in this way may take much longer to process than they would if they were submitted by your provider."
     
  3. DS4
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    DS4 Guru

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    Medicare providers are classified as,
    1) Participating
    2) Non Participating
    3) Opt out

    Under 1 & 2, provider must bill.

    Your clients provider probably outed out several years ago and Medicare is tardy in updating.

    Just my best guess.....
     
    DS4, Jan 11, 2016
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  4. FRJ
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    FRJ Super Genius

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    What is a Medicare Part B Carrier? First I've ever seen that.

     
    FRJ, Jan 12, 2016
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  5. somarco
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    somarco That Medicare Expert Guy

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    I had the same thought.

    I have had second hand interaction with some concierge practices and have yet to find one that will file claims for health insurance or Medicare.

    That is one of the benefits of a cash only practice.
     
    somarco, Jan 12, 2016
    #5
  6. MBSC
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    MBSC Expert

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    That is the old terminology for Medicare Administrative Contractor (MAC).

    Link: https://www.cms.gov/medicare/medica...actors/medicareadministrativecontractors.html
     
    Last edited: Jan 12, 2016
    MBSC, Jan 12, 2016
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  7. DS4
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    If a provider "opts out", they are required to have the patient sign an acknowledgment that the patient understands the provider operates on "cash only", and, does not bill insurance. Something to that affect.
     
    DS4, Jan 12, 2016
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