Author Topic: Billing Medicare when out of network  (Read 6713 times)

barb2512

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Billing Medicare when out of network
« on: December 16, 2013, 10:53:53 AM »
I work with a lot of LPC's that are master's level. Medicare does not recognize master's level clinicians. They can not become in network providers but more importantly, claims are not processed to be denied by Medicare or Medicaid. People come to see a master's level provider with medicare or Medicaid and have secondary insurance. So they want us to bill Medicare and get the denial and use that to bill the secondary. But Medicare does not even acknowledge they have received and rejected the claims. They never show in the Medicare system and we never receive correspondence back on these claims. So we can not bill the secondary either.

Has anyone ever figured out a way around this?

Thank you
Barbara

RichardP

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Re: Billing Medicare when out of network
« Reply #1 on: December 16, 2013, 11:50:31 AM »
You are correct that licensed professional counselors are a mental health discipline that is not covered by Medicare.  Therefore, Medicare will not process claims received from LPCs, just as they will not process claims received from my plumber.

Those commercial insurance companies that cover LPCs know this.  Each company would have it's own way of handling this.  You would need to contact each insurance that your LPC is a participating provider with and ask how they want you to handle this situation.

SLITTLES

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Re: Billing Medicare when out of network
« Reply #2 on: December 16, 2013, 12:54:36 PM »
I encounter this very often and I have contacted various companies to see how to handle this.

One carrier, we file the claim as normal then call in to have it reprocessed.

Another carrier, we file by paper with an explanation as well as the Medicare guidelines stating they can not bill Medicare.

It is definitely up to the carrier on how this is handled.
Shontel Littles
" Show Me The Money"

barb2512

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Re: Billing Medicare when out of network
« Reply #3 on: December 16, 2013, 01:10:15 PM »
Thank you both for your responses. I will work with your suggestions and glad to see something is working for you!!

Barbara

PMRNC

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Re: Billing Medicare when out of network
« Reply #4 on: December 16, 2013, 01:26:23 PM »
MY non Medicare clients just simply tell Medicare Patients that they are NOT Medicare providers. From there it's patients responsibility and choice. For those that come to see us anyway, they are treated as cash patients.
Linda Walker
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RichardP

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Re: Billing Medicare when out of network
« Reply #5 on: December 16, 2013, 07:33:19 PM »
Linda, for the sake of those who may not know, can you be a bit more specific on what you meant with your post.

We just went through this with a couple of our clients.  There are two states of being here:

Non-Participating Physician (with its attendant pay calculations) - must still file an insurance claim with Medicare.

Physicians who totally opt out of Medicare (good for two years at a time) - cannot file insurance claims with Medicare but must have a Private Contract with each Medicare patient who choses to see them.

It is a bit more complicated than simply treating Medicare folks as cash patients.

http://www.aapsonline.org/index.php/article/opt_out_medicare/

Part of the point of CMS is to protect Medicare folks from being treated as cash patients - where the patient can be charged whatever the doctor wants to charge, as allowed by his State regulations.  Bottom line, doctors can't ever really walk away from the Medicare regulations.  They have to follow them if the see Medicare folks, even if the doctor has opted out of Medicare - which they can only do for two years at a time (opt-out can then be renewed for another two-year stint).
« Last Edit: December 16, 2013, 07:37:14 PM by RichardP »

Merry

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Re: Billing Medicare when out of network
« Reply #6 on: December 17, 2013, 12:02:49 AM »
Your points are valid Richard but this is more than par or non par or opting out. This specialty is not covered by Medicare. So l agree with Linda. Would be the same as billing massage therapy to Medicare.

Merry

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Re: Billing Medicare when out of network
« Reply #7 on: December 17, 2013, 12:04:52 AM »
So we should change the subject line. This has nothing to do with a network. It is about a non covered specialty unlike an uncovered procedure.

RichardP

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Re: Billing Medicare when out of network
« Reply #8 on: December 17, 2013, 10:49:22 AM »
Merry - I was requesting clarification from Linda about this statement:

non Medicare clients ... [re.] Medicare Patients ... they are treated as cash patients.

I guess the key phrase here is "non-covered service".

From the link I provided above, re. the opt-out provider and private contracts:

Enter into a private contract for, and prior to, rendering any covered services ...

Key phrase in requirement for private contract is "covered services".  I missed that.  So it would seem that those Medicare patients seeking a non-covered service can indeed be treated as a cash patient.

Thanks for helping me clarify this to myself.



PMRNC

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Re: Billing Medicare when out of network
« Reply #9 on: December 17, 2013, 01:06:28 PM »
NO MEDICARE ACCEPTED for client(s) I was speaking of. I have one Masters level who NEVER got into Medicare and all rest of my clients with the exception of 1 OPTED out.  CASH Only at time of service. Yes it is that simple <g>
Linda Walker
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www.billerswebsite.com

RichardP

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Re: Billing Medicare when out of network
« Reply #10 on: December 18, 2013, 01:01:25 PM »
OK.  That response just confused me again.

It is my understanding that a doctor can see a Medicare patient only if s/he complies with one of three conditions - each of which has their own requirements.

1.  Participating Provider
2.  Non-Participating Provider
3.  Opted-Out

Are you aware of any conditions other than these three under which a doctor may see a Medicare patient and expect to get paid by someone?

It is my understanding that, if a doctor wishes to see a Medicare patient for a covered service, and he is not either PPO or non-PPO with Medicare, he must be in the opted-out category.  And this category requires that the doctor have a private contract with each patient for all covered services he performs.  Every. Time. He. Performs. Them.

It is my understanding that, for an opted-out doctor performing a covered service, it can never be cash-only at the time of service.  There must be a private contract established before the service can be performed, per the link I provided above.

What am I missing?

This is not an idle question.  We have a number of clients who would opt out, except for the private contract requirement (that requirement gets burdensom when they see many Medicare patients per day).  If that private contract requirement does not actually exist, it becomes a new ballgame.  Except that I have not found any documentation that says opted-out docs can see Medicare patients for covered services without that private contract being establish first.

PMRNC

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Re: Billing Medicare when out of network
« Reply #11 on: December 18, 2013, 02:30:46 PM »
I don't know what your missing.. again:

NO MEDICARE ACCEPTED for client(s) I was speaking of. I have one Masters level who NEVER got into Medicare and all rest of my clients with the exception of 1 OPTED out.  CASH Only at time of service. Yes it is that simple <g>

there is NO MEDICARE PERIOD. Those providers have notified and adhered to Medicare opt out for the one that opted out.. for the other who was NEVER in Medicare, no further explanation is needed. CASH pay. I'm not sure what you are missing, but we are not missing anything.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

RichardP

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Re: Billing Medicare when out of network
« Reply #12 on: December 18, 2013, 04:50:10 PM »
Linda - my question is a serious one, and your response doesn't seem to be serious.  I listed three options for doctors regarding Medicare, and none of them grant the freedom that you are claiming.  So my question, seriously, is there a fourth option that I am missing?

It seems that you are defining a fourth category of doctor - those who were never part of Medicare to start with.  Serious question, so serious answer please.  Can a doctor get his license to practice medicine and never deal with Medicare from the get-go?  (I thought every doctor had to place themselves into one of the 3 categories I listed above.)  If so - that would be a fourth category that I was not aware existed.  But that is not the case with any of our clients.  None of our clients has never had any dealings with Medicare.  I imagine that is the rule for most medium to small billers.

A while back you commented that all of your clients were now Medicare-free.  If you stated somewhere that some of them were Medicare-free because they had never ever had any dealings with Medicare, I missed that.  It appeared to me that you had opted all of them out.

Those providers have notified and adhered to Medicare opt out for the one that opted out ...

I presume this one is renewing his opt-out status every two years, and is creating private contracts for all Medicare patients who are receiveing covered services?  If yes, that is not an experience as simple as a cash patient.  And if no, I would hope s/he doesn't get turned in.

PMRNC

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Re: Billing Medicare when out of network
« Reply #13 on: December 18, 2013, 05:18:46 PM »
Richard, I think your making too much out of nothing.

The one provider I have has NEVER had a thing to do with Medicare.. period.. what she does, what she charges.. is MOOT. She has that right.

The other one I'm speaking of (dealing with mental health) OPTED OUT OF MEDICARE.. did the whole legal mumbo jumbo to opt out. So what she charges.. is also MOOT. She has notified patients legally as per the opt out and her affidavit sent in.

I don't KNOW what you are reading..but those providers who have NEVER taken Medicare or opted OUT of Medicare have nothing to do with Medicare.. Period. It really IS THAT SIMPLE!!   My providers with the exception of ONE.. have opted out of all govt payors. They are now NO longer controlled at ALL by govt payor rules. PERIOD.    I have ONE client taking medicaid but ONLY until 4/1 and then I will be completely OUT of billing all govt payors.
Linda Walker
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DMK

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Re: Billing Medicare when out of network
« Reply #14 on: December 18, 2013, 05:29:40 PM »
You have to register with Medicare for them to even know you exist.  If you never register, Medicare doesn't know who you are and you can not bill them, even for a denial.  You don't exist to them.  It IS a doctor's choice to take insurance (any insurance) or not.  You can charge cash pay to anyone you want.  Where you run into the issues is when you HAVE signed up with insurance or Medicare and then you try to negotiate a price with the client. You don't get to do that without jumping through a bunch of hoops.

If the provider provides a service not covered by Medicare, what would be the point in signing up or opting out?  It's not necessary, just charge a cash fee schedule.