Plan N Question

[vic120]

I have always had the understanding that with Plan N the $20 only applies to doctors visit and not for therapy of any kind

I have a client that is about to begin cardiac therapy Now after some heart Issues, The Therapy place is telling him this is Not true and he will have to pay a $20 copay for each therapy visit.

He did inform them That I told them that this $20 copay should only apply if it is a doctors visit and they told him this is in fact Not true and he will have to pay

Is he responsible for the copay and am I wrong?

If he should not pay a copay, How should he handle this?

 

[Chazm]

He is not. It’s beeb discussed here a few times and it needs to be coded correctly. I would call the insurance company and find out.
Come back here and post

 

[Travis Price]

I agree. Plan N costs is for Doctor visits. PT, OT, Cardiac Rehab are not Doctor visits.

I'm looking it up currently

 

[vic120]

He is not. It’s beeb discussed here a few times and it needs to be coded correctly. I would call the insurance company and find out.
Come back here and post

The thing is he has not begun yet and has not got bills, He just went there to set up

And this is where they are telling him he will need to be sure to pay $20 upfront on every therapy session

So there would be nothing on Ins company records as far as coding and what not, Also if he had bill already I would normally have him send to me so I can call Ins company and provider, However without a bill I have nothing but what they are saying

Its the only place around he wants to go to, I need to know what to tell him as far as what to say to them beyond Just that it is not supposed to charge a copay for therapy because he is getting nowhere with that alone

 

[Travis Price]

The thing is he has not begun yet and has not got bills, He just went there to set up

And this is where they are telling him he will need to be sure to pay $20 upfront on every therapy session

So there would be nothing on Ins company records as far as coding and what not, Also if he had bill already I would normally have him send to me so I can call Ins company and provider, However without a bill I have nothing but what they are saying

Its the only place around he wants to go to, I need to know what to tell him as far as what to say to them beyond Just that it is not supposed to charge a copay for therapy because he is getting nowhere with that alone

Chaz is correct. Services coded as OV's or evaluations and management Codes 99201-99205 and 99211-99215, as well as 92002, 92004, 92012, 92014 and 90805.

It's covered under CMS.

Call the Cardiac rehab, as to speak to billing. Ask them what code they use for cardiac rehab visits when billing Medicare.

 

[hockeyday]

I have always had the understanding that with Plan N the $20 only applies to doctors visit and not for therapy of any kind

I have a client that is about to begin cardiac therapy Now after some heart Issues, The Therapy place is telling him this is Not true and he will have to pay a $20 copay for each therapy visit.

He did inform them That I told them that this $20 copay should only apply if it is a doctors visit and they told him this is in fact Not true and he will have to pay

Is he responsible for the copay and am I wrong?
It's not even 20 dollars, it's up to 20, I have a number of people on N and they never get a bill, provider just aspects what medicare pays..
Tell him to tell them to just bill medicare, if they code it wrong to medicare that is an illegal act on their part, the provider does not bill the med sup company

If he should not pay a copay, How should he handle this?

 

[Travis Price]

This is not correct. Here is the CMS guidelines https://www.cms.gov/Medicare/Health-Plans/Medigap/Downloads/Plan_N_Guidance2.pdf

See my above post that pulls the codes from that guidance.

Medicare cardiac rehab code is 93797, 93798

PT is 97032, 97032-33, 97035, 97039

Or non supervised 97010, 97012, 97014, 97024, 97026, 97028

Or 97110, 97112, 97116, 97124, 97139, 97140, 97530

 

[vic120]

It is an office visit. Subject to $20 copay according to that document.

An office visit to my understanding is when its either a doctor visit or an evaluation

As far as I understand If you go in for just a test or for a therapy visit It should Not be an office visit

If I am wrong please show me

But this was my understanding for years I learned that here and only now am I having an issue for the 1st time

Maybe something has changed IDK that is why I started thread

 

[Travis Price]

Yes, by code for an office visit. They are obviously coding it that way, which to me seems correct, so it is by definition an office visit and subject to the copay.

Except I just gave you the code for Cardiac Rehab, which is not those codes.

 

[hockeyday]

An office visit to my understanding is when its either a doctor visit or an evaluation

As far as I understand If you go in for just a test or for a therapy visit It should Not be an office visit

If I am wrong please show me

But this was my understanding for years I learned that here and only now am I having an issue for the 1st time

Maybe something has changed IDK that is why I started thread

You not wrong, I have never had a plan N person get billed, the document say doctor, pt is not a doctor visit,