Part B Claims

[steveadlman]

I have a client that just went to his primary care doctor for the first time since going on Medicare. He has his Supplement with Aetna. The doctor's office told him they would file with Medicare but he would have to pay the coinsurance and the deductible in order to see the doctor. The office manager told me that is how they handle all of their Medicare patients unless they have an Advantage Plan and they are in network with that plan. Is it legal to collect the coinsurance in advance without first filing the claim with his Supplement? The office manager said after the Supplement pays them they would reimburse the patient. INSANE!

 

[WCMason]

I have a client that just went to his primary care doctor for the first time since going on Medicare. He has his Supplement with Aetna. The doctor's office told him they would file with Medicare but he would have to pay the coinsurance and the deductible in order to see the doctor. The office manager told me that is how they handle all of their Medicare patients unless they have an Advantage Plan and they are in network with that plan. Is it legal to collect the coinsurance in advance without first filing the claim with his Supplement? The office manager said after the Supplement pays them they would reimburse the patient. INSANE!

Based on this description your client is likely seeing a “non-par” doctor. They are allowed to charge in full at time of service and add an excess charge, too, though not all do. They file the claim with Medicare only (whether the provider accepts assignment or is non-par), never with the Medigap carrier. Medicare coordinates payment with the supplement carrier.

 

[somarco]

Wes is probably on to something here. Rarely happens that you encounter a doc that does not participate in Medicare, but you and your client can use the provider lookup tool on Medicare.

Never understood how or why they would effectively "opt out" of original Medicare but "opt in" to a managed care plan.

Might be time to look at a new PCP.

 

[Hopes]

Trying to understand....Could this be a reason that doctors would approach billing this way?

I had a client whose Pt B started after Pt A. She left her group plan and enrolled in a med supp.

When she went to the doctor, they billed Medicare and the claim was denied. Apparently, the "system" showed that she was still enrolled in her group plan (the group plan did not terminate in the system). So Medicare became secondary.

She had to call Medicare and tell them the date the group plan terminated and then Medicare became primary.

 

[WCMason]

Trying to understand....Could this be a reason that doctors would approach billing this way?

I had a client whose Pt B started after Pt A. She left her group plan and enrolled in a med supp.

When she went to the doctor, they billed Medicare and the claim was denied. Apparently, the "system" showed that she was still enrolled in her group plan (the group plan did not terminate in the system). So Medicare became secondary.

She had to call Medicare and tell them the date the group plan terminated and then Medicare became primary.

I see this happen from time to time. If Medicare is not notified that the employer coverage has been dropped they will not pay claims waiting for that primary insurance from the employer to pay first. I found the easiest way to resolve this is for the client to call Medicare’s Coordination of Benefits office at 800-999-1118 to notify the that the employer coverage is gone. Usually the doctor will need to re-file the claim with Medicare after the employer plan no longer shows as primary and it should go through.

 

[Hopes]

I see this happen from time to time. If Medicare is not notified that the employer coverage has been dropped they will not pay claims waiting for that primary insurance from the employer to pay first. I found the easiest way to resolve this is for the client to call Medicare’s Coordination of Benefits office at 800-999-1118 to notify the that the employer coverage is gone. Usually the doctor will need to re-file the claim with Medicare after the employer plan no longer shows as primary and it should go through.

Good to have this number handy, thanks!

I'm thinking I need to let clients know up front this can happen.

The billing person for said client was genuinely confused about the whole thing. Truth be told, I was too until I spoke with Medicare to clarify.

 

[steveadlman]

Based on this description your client is likely seeing a “non-par” doctor. They are allowed to charge in full at time of service and add an excess charge, too, though not all do. They file the claim with Medicare only (whether the provider accepts assignment or is non-par), never with the Medigap carrier. Medicare coordinates payment with the supplement carrier.

I did look them up on the provider lookup tool and it states they "May accept Medicare-approved payment amounts".

 

[somarco]

they "May accept Medicare-approved payment amounts".

Which means they also may not . . .