Author Topic: Wrong payor  (Read 2473 times)

DONNA

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Wrong payor
« on: August 02, 2009, 08:17:48 PM »
We are a radiology facility and we par with Medicare. When the patient comes in they will give us their Medicare as prim and a commercial ins. as 2nd. Then the denial comes in or we call the voice response  we are told we must send to correct payor. Now we call the patient, many do not understand that they have Medicare HMO. This happens on a regular basis. We have the front desk ask them again "do you have an HMO Medicare" Reply "NO". Now its over a month the patient has for ex. Medicare Blue, to late to get an authorization because they can't back date, our claim is denied for no authorization. I document everything do an appeal and of cause the appeal is denied. Can the patient be billed since it was not our error we didn't get the auth, but had we have known they had an hmo we would have gotten the auth. If any one else is having this problem or not what are you asking these patients to get the correct information from them..
thanks for your help ??? ???

Michele

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Re: Wrong payor
« Reply #1 on: August 03, 2009, 06:21:46 AM »
I think the problem is in the wording "Do you have a Medicare HMO"  They don't know what a Medicare HMO is.  We always suggest asking "Do you have any other medical cards?  Did you sign up for Medicare through another company that contacted you about your Medicare?"  Most don't know what they signed up for, but if you prompt them a little bit, they remember.  It also helps if you name some of the more popular ones.  "Todays Options, Blue Cross, etc."  If you say the name of theirs they usually almost jump, or if they have a different one, they show interest in what you are saying, but if they have straight Medicare they don't usually have any idea what you are talking about.  I know it's difficult, but it saves in the long run! 

As far as can the patient be billed, you will have to check with the carrier, BC in the example below.  You don't want to do anything to break your contract.

Michele
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PMRNC

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Re: Wrong payor
« Reply #2 on: August 03, 2009, 09:39:51 AM »
You have to get the Patient's card so that you can verify the benefits.

I had a client who used to ask "Have you received any free things after a lunch or breakfast at Denny"s" and this usually prompts them to remember. Bottom line is that you must get the card and verify information. I'm not sure you can bill the patient now.
Linda Walker
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Pay_My_Claims

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Re: Wrong payor
« Reply #3 on: August 03, 2009, 11:07:42 AM »
An insurance card means NOTHING!!!  Agreeing with Linda you have to VERIFY the insurance. They do think that they have Medicare and the other insurance is 2ndary, but its probably a replacement plan. We go through it all the time that is why I verify first. One positive thing is now they are stricter on the medicare PFFS's that when you enroll you are obligated for that year. You used to be able to come in and out of them, but it was horrible then. clients would be in reg medicare one month and a PFFS the next!!

Hard lesson, but if they are pre-scheduled appointments, someone needs to be checking the IVR or some other source (passports, CSI/ELIG) system for medicare eligibility.

Steve Verno CMBS, CEMCS

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Re: Wrong payor
« Reply #4 on: August 07, 2009, 05:07:03 PM »
In many CMS newsletters Ive read over the years, CMS has stated many times, it is up to the provider to check Medicare and HMO eligibility.  Sometimes elderly patients become confised as to what coverage they have.  I know, ask my 76 year old mom.  She's always calling me saying she got a bill.  She always gives both her Medicare and Medicare HMO card at the same visit.  To her, Medicare is primary and the Medicare HMO is secondary  She doesnt realize she joined a Medicare Advantage carrier.

Here is an excellent reference tool
http://www.cahabagba.com/rhhi/education/materials/fiss_elig.pdf
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
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You got your peanut butter on my milk chocolate.
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Pay_My_Claims

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Re: Wrong payor
« Reply #5 on: August 07, 2009, 07:48:54 PM »
You have to get the Patient's card so that you can verify the benefits.

I had a client who used to ask "Have you received any free things after a lunch or breakfast at Denny"s" and this usually prompts them to remember. Bottom line is that you must get the card and verify information. I'm not sure you can bill the patient now.

OMG, not Denny's!!

PMRNC

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Re: Wrong payor
« Reply #6 on: August 08, 2009, 09:03:11 AM »
yes Denny's .. don't laugh but I worked there for years..when in H.S and later on when I was in college.  You wouldn't believe how many of those insurance agents would rent out the small room and hold these free breakfast's for seniors so they could sell them coverage they didn't need.
Linda Walker
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Steve Verno CMBS, CEMCS

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Re: Wrong payor
« Reply #7 on: August 08, 2009, 09:10:25 AM »
I'll take the limited pay nothing HMO policy to go with my Moons Over My Hammy breakfast please an can I have a side order of non covered services with sausage gravy and biscuits?
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.