Author Topic: Billing Medicare when out of network  (Read 7323 times)

PMRNC

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Re: Billing Medicare when out of network
« Reply #15 on: December 18, 2013, 05:53:44 PM »
Exactly DMK....    Too many people think the govt is invincible. I happen to be lucky enough to find providers who believe it is THEM that make up the Govt healthcare system, without them they system will come to a screeching halt.

NO MEDICARE.. cash.   We better start getting used to it.
Linda Walker
Practice Managers Resource & Networking Community
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www.billerswebsite.com

RichardP

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Re: Billing Medicare when out of network
« Reply #16 on: December 18, 2013, 10:38:03 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.

None of those sentences are correct.  See below.

Quote
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.

That is not correct.  See below.

Quote
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.

That is not correct.  They (and you as their biller) are still subject to the Social Security Act, whether they and you know it or not.  And that governs their allowed behavior with Medicare patients seeking covered services, even from a doctor who has never signed up to be any part of Medicare.
------------------

Your clients may get away with doing all that you say is correct above.  But whether those behaviors comply with the law is another matter entirely.  I have been blindsided by your comments, seriously, and do not have the time right now to find appropriate original legal sources.  So I will provide these two resources on short notice, since they are handy.

1.  I refer you again to the link I provided above, and direct you to the requirements contained in the opt-out section.  You can find more specific versions of these requirements by searching the Internet.  The opt-out must be renewed every two years.  And the opted-out provider must comply with CMS requirements if s/he is going to see Medicare patients.  By law, they cannot see Medicare patients for covered services without first having created a private contract that is signed by both the doctor and the patient (see my link above).  Your clients may not be doing this, but they are not legal.  And neither are you, if you bill for them.  Your clients are required to know what I have just stated.  And, as their biller, so are you required to know this.  If you are hauled into court, you cannot use ignorance as a defense.  By law, an opted-out doctor is still subject to CMS regulations regarding Medicare patients seeking covered services - which is in contradiction to what you have claimed.  They may charge the patient whatever they wish to charge for covered services, but only if they do so in accordance with Medicare rules.  An opted-out doctor is not freed from Medicare / Social Security Act regulations just because s/he has opted out.

2.  This quote is from here:

http://www.drjarodcarter.com/accepting-out-of-pocket-payment-from-medicare-patient/

If a Physical Therapist provides services to a Medicare beneficiary that would normally be covered by Medicare, he/she is required to bill Medicare directly and is not allowed to accept self-payment for these services. The Social Security Act has a mandatory claims submission requirement, so a Physical Therapist cannot choose to not enroll in the Medicare program AND collect cash from a Medicare beneficiary [for covered services].

When you hear about health care practitioners “opting out” of Medicare, please know that this is actually a different scenario than that described above. Physical Therapists are not included in the list of practitioners who can “opt out” (outlined in the Balance Budget Act of 1997 and Medicare Prescription Drug Improvement, and Modernization Act of 2003); However, this does not mean we are required to accept Medicare beneficiaries as patients. It is always our choice as to who we accept as a patient; but if that patient is a Medicare beneficiary then we can only accept self-payment from them if the services are considered “non-covered” by Medicare.

This is a health-care provider acknowledging that the Social Security Act binds all doctors to government regulations when they are seeing Medicare patients for covered services, regardless of whether they are non-participating, opted-out, or never joined Medicare to begin with.
------------------

This is what I know.  This is the advice upon which I have always operated.  If you have a link to government language that has rescinded the requirements of the Social Security Act I referenced above, I would love to have it.  It would make life for my clients so much simpler.

Given that this is a site for educating actual billers and potential billers about the process, and also about the law, involved with billing, I am quite taken aback by what Linda has said, as quoted above.  But if she can point me to legal language that rescinds the legal language I pointed to, I will accept that she is not seriously misleading her readers on this issue.

I saw that there are other comments below Linda's.  I have not read them yet.  If they require a response from me, I will respond in a different post.

RichardP

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Re: Billing Medicare when out of network
« Reply #17 on: December 19, 2013, 02:30:44 AM »
I've had some time to locate the legal source code to support my claims in my previous post.

Thanks to Merry and Linda for alerting me that there is, indeed a fourth category.  I have never had reason to know that this fourth category existed.  But it's existance is of no help to us and our clients, as non-enrolled physicians may not bill patients for covered services.

From here:  http://www.jpands.org/vol18no1/hansen.pdf

Top Left of article:

Enrolled:

  1.  Participating
  2.  Non-Participating
  3.  Opted Out  - Medicare will not reimburse patient

Not Enrolled:

  4.  Non-Enrolled, or UnEnrolled

We already know what the CMS requirements are for obtaining payments in Categories 1-3.  And there are requirements.  The doctor cannot just charge the patient in whatever way he wishes to for covered services.

What about the fourth category - non-enrolled or unenrolled?

Right-hand Column - first page of article at above link:

Social Security Act Section 1802 [42 U.S.C. 1395a] FREE CHOICE BY PATIENT says:

Any individual entitled to insurance benefits under this subchapter may obtain health services from any...person qualified to participate under this subchapter if such...person undertakes to provide him such services.

This would seem to indicate that a Medicare patient could seek covered services from a non-enrolled physician.  Unless maybe a non-enrolled physician is not a qualified participant under that sub-chapter.

From here:  http://www.law.cornell.edu/cfr/text/42/424.505

 42 Code of Federal Regulations says:

 § 424.505
Basic enrollment requirement.

"To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program.

To be enrolled in the Medicare program, to be able to receive payment from Medicare or patient for covered services, the physician must be in one of Categories 1-3 listed at the top of this post.  The fourth, or non-enrolled category cannot receive payment for covered Medicare items or services - from either Medicare or patient - because a provider or supplier must be enrolled in the Medicare program to receive payment for covered services that were provided.  According to 42 CFR, Section 424.505, an un-enrolled physician cannot charge either Medicare or the patient for covered services.

Furthermore, Medicare patients may not seek reimbursement from Medicare for payment to a non-enrolled physician for covered services - as demonstrated by the following Resolution:  (from the link at the top of this post)

The California Medical Association's Delegation to the American Medical Association (AMA) offered the following resolution, which was adopted by the November 2012 AMA House of Delegates:

RESOLVED: That our American Medical Association support every physician’s ability to choose not to enroll in Medicare (New HOD Policy); and be it further RESOLVED:  That our AMA seek the right of patients to collect from Medicare for covered services provided by unenrolled or disenrolled physicians.

I will leave this link here just for reference, as it points to relevant Code sections.

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Part%20B~Browse%20by%20Topic~Provider%20Enrollment~Opt%20Out~8EELV85150?open&navmenu=Browse^by^Topic||||

PMRNC

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Re: Billing Medicare when out of network
« Reply #18 on: December 19, 2013, 06:10:55 PM »
With all due respect, I always appreciate information.. I'm willing to always learn as we have to in this industry. One thing I have learned in past few years doing MORE consulting than actual billing is to NOT take any measures with regards to opt out without the practice's legal adviser signing off. The provider's I have worked with in "opting out" over the last 18 mos-2 years are all completely covered.. everything done.. i's dotted and t's crossed. AND not without legal sign off because of the requirements with the affidavit's. Believe me, I had providers who wanted OUT OUT and didn't care what the bottom line was.. it was a matter of principal. I also consulted with providers who just simply wanted to stop seeing NEW patients. We often get confused with all the different relationships with Medicare, NON enrolled, non par, par, accept assignment, etc etc..      I've also consulted with physicians and attorney's in really well off areas of NJ where I grew up where patients could actually choose to pay cash AND DO to providers NOT enrolled or opted out of Medicare.

I'm well aware of the fact that PT's and Chiropractors cannot OPT out.. I don't work with either specialty, I'll be clear about that.. those who know me know I'd rather starve than work with a chiropractor. <g>

On to the legal MUMBO Jumbo:
 
The potential fourth option spoken about  is nonenrollment. A physician who
chooses not to enroll is not entitled to bill Medicare at all.
Such
physicians bill patients directly and determine their own fees.
Patients may seek reimbursement from Medicare. The following constitute the basis for this option in law:
Sec. 1802. [42 U.S.C. 1395a] FREE CHOICE BY PATIENT.
(a)

Any individual entitled to insurance benefits under this subchapter may obtain health services from any institution, agency, or person qualified to participate
under this subchapter if such institution, agency, or person undertakes to provide him such services.
  IN PLAIN ENGLISH.. IT IS MY MONEY AND I CAN SPEND IT WHERE I WANT TO

Further more, The Social Security Act refers to nonparticipating physician who is enrolled in Medicare, not to an individual
physician who is not enrolled:


(g) Limitation on Beneficiary Liability. (1) Limitation on actual charges. (A) In general.—In the case of a
nonparticipating physician or nonparticipating supplier or other person (as defined in section 1842(i)(2)) who does not accept payment on an assignment-related basis for a physician’s service furnished with respect to an individual
enrolled under this part, the following rules apply: (i) Application of limiting charge.—No person may bill or collect an actual charge for the service in excess of the
limiting charge described in paragraph (2) for such service. (ii) No liability for excess charges.—No person is liable for
payment of any amounts billed for the service in excess of such limiting charge. As some physicians have pointed out, ambiguity arises because of Medicare’s use of the term“nonparticipating.” (2) The term “participating physician” refers, with respect to the furnishing of services, to a physician who at
the time of furnishing the services is a participating physician (under subsection (h)(1)); the term “nonparticipating physician” refers, with respect to the
furnishing of services, to a physician who at the time of furnishing the services is not a participating physician; and
the term “nonparticipating supplier or other person” means a supplier or other person (excluding a provider of services) that is not a participating physician or supplier (as defined in subsection (h)(1)). (h)(1) Any physician or supplier may voluntarily enter
into an agreement with the Secretary to become a participating physician or supplier. For purposes of this
section, the term “participating physician or supplier” means a physician or supplier (excluding any provider of
services) who, before the beginning of any year beginning with 1984, enters into an agreement with the Secretary which provides that such physician or supplier will accept payment under this part on an assignment-related basis for all items and services furnished to individuals enrolled under this part during such year. In the case of a newly licensed physician or a physician who begins a practice in a new area, or in the case of a new supplier who begins a new business, or in such similar cases as the Secretary may specify, such physician or supplier may enter into such an
agreement after the beginning of a year, for items and services furnished during the remainder of the year.

The key point is that
.
Sec. 1842. [42 U.S.C. 1395u] (h)(1) defines a “participating” physician as one who agrees to accept payment from Medicare on an assignment-related basis for all items and services. Although Sec. 1842 is silent on the prerequisite enrollment requirement, Sec. 1866 (vide supra) makes it clear that only a physician who chooses to file an agreement with the Secretary is qualified to participate
in Medicare and is eligible for payments from Medicare. Some physicians, for instance pediatricians, are unlikely to provide medical care to Medicare beneficiaries.
Some physicians want to maximize their patients’ Medicare Part B benefits. Medicare beneficiaries forfeit their Part B benefits if their physician opts out of Medicare, so many physicians who contract privately with their patients desire a different relationship with Medicare than enrolling and then opting out.
Some physicians want to give patients the extra time and attention they need through home visits and other special
services.
Some physicians want to protect their patients’ privacy. For instance, many psychiatrists consider production of medical records for third-party review an unethical breach of patient confidentiality. Since Medicare reserves the right to review medical records of physicians enrolled in the system, some
physicians choose not to enroll in Medicare. Some physicians believe Medicare’s bureaucratic hassles are too time-consuming. Some physicians believe that the federal government does not have the authority to conscript every single physician into a centrally planned health system and
punish those physicians who refuse by taking away their patients’ Medicare benefits.
Some physicians cannot enroll in Medicare in a timely manner. In order to provide medical care during a protracted enrollment process, some physicians bill their patients and then assist these patients to seek reimbursement directly from Medicare.
before the issue of participating or non- participating is reached, a physician must have already voluntarily enrolled
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

PMRNC

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Re: Billing Medicare when out of network
« Reply #19 on: December 19, 2013, 06:28:26 PM »
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf

FIRST PAGE:

01
-
Foreword
(Rev. 2783, Issued: 09
-
10
-
13, Effective: 09
-
30
-
13, Implementation: 09
-
30
-
13)
Generally, this chapter describes policy
applicable to Medicare fee
-
for
-
service claims, or
what is known as the original or traditional Medicare program. See the Medicare
Managed Care Manual for services to enrollees in managed care plans.
Unless specified otherwise the instructions in this cha
pter apply to both providers and
suppliers, and to the contractors that process their claims.
In this chapter the terms provider and supplier are used as defined in
42 CFR 400.202
.

Provider
means a hospital, a CAH, a skilled nursing facility, a comprehensive
outpatient rehabilitation facility, a home health agency, or a hospice that has in
effect an agreement to participate in Medicare,
or a clinic, a rehabilitation agency,
or a public health agency that
has in effect a similar agreement but only to furnish
outpatient physical therapy or speech
-
language pathology services, or a
community mental health center that has in effect a similar agreement but only to
furnish partial hospitalization services.

Supplier
means a physician or other practitioner, or an entity other than a provider
that furnishes health care services under Medicare. A supplier must meet certain
requirements and enroll as described in Chapter 10 of the Medicare Program
Integrity Manual.

A provider that meets the applicable conditions may also enroll
as a supplier of a particular service and may bill separately for that service where
Medicare payment policy allows separate payment for the service.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Merry

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Re: Billing Medicare when out of network
« Reply #20 on: December 19, 2013, 10:01:40 PM »
But we are not talking about a service not covered here. We are talking about a provider that cannot participate in Medicare, whether as par, non par or opt out coz you cannot opt out of something that you were never in.
You cannot bill Medicare and get a denial as the specialty is not covered. This is different than a non covered service where you would get an ABN signed if you were billing just to get the denial. Acupuncture and massage therapy..Really the same situation. Some insurance companies cover these but you cannot send to Medicare to get a denial so that you can bill the secondary.

Merry

PMRNC

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Re: Billing Medicare when out of network
« Reply #21 on: December 20, 2013, 02:11:43 PM »
NO.. not even that.. there are provides who have NOT even chose ENROLLMENT with Medicare. EVER.. NO RELATIONSHIP EVER.  COVERED OR NOT.. those providers are NOT under any obligation with medicare.. PERIOD.  eligible or not.. many providers were smart enough from the get go NOT to even enroll.. PERIOD. case closed.
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 #22 on: December 31, 2013, 03:14:11 AM »
Linda - nothing you have posted overrides the reality of this - copied from my post above.

42 Code of Federal Regulations says:

 § 424.505
Basic enrollment requirement.

To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program.


To be enrolled in the Medicare program, to be able to receive payment from Medicare or patient for covered services, the physician must be in one of Categories 1-3 listed at the top of [the post this was copied from].  The fourth, or non-enrolled category cannot receive payment for covered Medicare items or services - from either Medicare or patient - because a provider or supplier must be enrolled in the Medicare program to receive payment for covered services that were provided.  According to 42 CFR, Section 424.505, an un-enrolled physician cannot charge either Medicare or the patient for covered services.
----------

Medicare’s current interpretation of Social Security Act (SSA) Section 1848 is that a nonenrolled physician must provide medical care free of charge.  In November 2011, the American Medical Association published an unsigned email from a federal employee that made this position crystal clear: “... [A] physician who treats a Medicare beneficiary...must either...enroll in Medicare...or... furnish the Medicare-covered services for free.

From bottom-right of first page of this link.
http://www.jpands.org/vol18no1/hansen.pdf

I'm not debating when and where this regulation might be enforced.  Nor am I debating whether it should be enforced.  I am saying there is a regulation on the books that contradicts your advice that a non-enrolled or de-enrolled provider can charge his Medicare patients in whatever manner he deems fit, for covered services.

The intent of the Social Security Act is to protect all Medicare patients in every instance they interact with a provider for covered services.  Therefore, it is not correct to teach people that the government has no authority over a non-enrolled or de-enrolled provider.
------------------

Linda, I know that you know how to read.   And I presume that you know the quote I provide at least twice in this thread (once, above, in this post) is taken from the Code of Federal Regulations.
If these two things are true, then you are making yourself look awful silly by continuing to claim that non-enrolled and de-enrolled providers are no longer under the authority of the Social Security Act.  By virtue of the Act protecting Medicare patients for every encounter with a provider for covered services, every provider who sees a Medicare patient for a covered service is made subject to the authority of the Social Security Act, and, by extension, the Federal Government.

(I've been gone, or I would have posted this response sooner.  And since Section 424.505 of 42 US Code of Federal Regulations has not been repealed, there is nothing more for me to say on this.)
« Last Edit: December 31, 2013, 03:28:24 AM by RichardP »