Q about Hospital billing code: Part B or D?

[fun2drum]

I have a situation with a Med Supp client. He went to the ER and was administered a nasal drug while being treated there. The hospital billed Medicare with a code that would indicate it was a Part D drug, so Medicare correctly didn't pay the claim since it wasn't coded as administered at the hospital facility. My client called Medicare on speakerphone with me in the room, explained the situation, and the Medicare rep told us that if it had been coded differently then it would have been covered by Part B, which is what I already assumed.

My client called me today from the hospital billing office, and told me they insisted that they billed it right as a Part D drug even though it was given to him while receiving treatment in their ER. They've effectively made it impossible for him to get the drug covered since as far as I'm aware, it must be a pharmacy in network to bill a Part D plan, right? And it must be billed as a Part B covered drug if it was given to him while receiving treatment in the ER, right? Am I missing something?

I'm seriously starting to wonder if there's some exception that I haven't realized all these years, so I'd like to hear your opinions and/or advice I can give to my client on what to do next. File a grievance with the hospital or with Medicare?

 

[somarco]

How much money are we talking about here. For the drug. I presume the hospital extracted their pound of flesh to administer the drug via the ER.

The bill for the drug probably was miscoded. Getting hospital to admit and correct will be a problem. Local hospital affiliated lab miscoded a Welcome to Medicare test on me that resulted in Medicare running it through the B deductible. I fought with them (lab) for 6 months before finally paying it before they turned it over to collections.

In my case, and yours as well, Medicare probably won't do anything unless there is a significant amount of $$$ on the line.

 

[LostDollar]

(caveat, not an agent)

Awhile back, bevo or wcmason posted a link to an organization they had found effective in helping clients with medicare billing issues.

I can't think of search terms to turn the post up quickly. If the issue is important enough to you, you could work on hunting up that post-or you could just pm them and ask-whichever one made the post could give you the info on an agent to agent basis.

(I would not suggest mentioning my name as a referral source in a pm to wcmason.)

 

[DS4]

https://www.medicare.gov/pubs/pdf/1...Administered-Drugs-in-Hospital-Outpatient.pdf

 

[DS4]

(I would not suggest mentioning my name as a referral source in a pm to wcmason.)

This is the correct way to summon Wes Mason.

 

[fun2drum]

https://www.medicare.gov/pubs/pdf/1...Administered-Drugs-in-Hospital-Outpatient.pdf

Thank you, that is very helpful.