Author Topic: Need a Medicare deductibles/copays/coinsurance 101 quick overview please!  (Read 2671 times)

TMCGEATH

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This past year was the first time I'd billed Medicare for two of my providers - I did not start off with them at the beginning of the year so this is new to me.

I understand the provider cannot collect from a Medicare patient until the EOB comes in and states what their financial responsibility will be.

I got these EOB's in and let my providers know what each Medicare patient now owed from the beginning of the year.

But from their questions I need some help!

If the patient has a medicare supplement policy - do these policies pay the deductible amount?

I noticed last year that it seemed I didn't have to send a claim myself to the secondary insurance - Medicare forwarded it automatically (I'm assuming for every Medicare patient that had a supplemental plan).

I also noticed that if a supplemental plan paid the copay/coinsurance amount, the payment would sometimes comes fast and sometimes would take months and months.

How are providers supposed to know what to do? How do I know what to advise them?

I know I haven't explored my area's medicare administrators site to it's full extent - is it possible this site may have more answers for me?

Thanks in advance for any help anyone can give!

Tracie McGeath
Precision Billing and Business Services

Merry

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there is a difference between a supplemental and a Medigap pollicy. Deductibles are often met depending on the policy. There is no iron clad rule. You Medicare forwards only on assigned claims to a Medigap carrier..not a supplemental

You REALLY need to learn Medicare if you are getting involved with these patients.
I would suggest that you get our course on Medicare ..medicalbillingstudycourse.com which is really an extensive (and intense) course. I think that it will really help you.

Merry

kristin

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1. Not every secondary policy pays for deductible amounts. It depends on what policy the patient has.
2. Most secondary plans have a crossover with Medicare, so you do not have to send the claim yourself. For those that don't, you do need to send the claim in, along with a copy of Medicare EOB for the claim. Your Medicare EOB/ERA will tell you if the claim has been forwarded to the secondary payer, or not. Some payers do not accept electronic submission, so you have to send paper claims.
3. Different plans pay at different speeds. Most adhere to 30 days or less from date they received claim, but not all. Those you have to submit yourself will take longer, usually.
4.What you can advise your providers is in answers 1-3, for a start. There is nothing special to this process. You submit claim to Medicare, they apply charges to deductible, they forward to the secondary in most cases, and the secondary either pays for deductible, or does not. Patient is billed what they owe after that.

TMCGEATH

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Merry, I definitely still think about doing that Medicare portion!

Kristin, thank you so much! It was so nice having your response so well written out and summed up!
Tracie McGeath
Precision Billing and Business Services

PMRNC

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    • One Stop Resources & Networking for Medical Billers
Quote
I understand the provider cannot collect from a Medicare patient until the EOB comes in and states what their financial responsibility will be.

That's not exactly true, you are allowed to collect deductible and coinsurance at time of service just like any other patient. Medicare patients do still have OOP. MOST practices don't like to collect the deductible up front since it's a low deductible and Most Medicare patients meet their deductibles very quickly. Coinsurance however can be calculated from the fee schedule and requested at the time of service.

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

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JMHO - I keep a list of regularly billed codes, allowed amounts and co-pays.  That way I KNOW exactly what I can collect.

If you know the patient has a secondary or supplemental, check the coverage, then you know if the patient will ever have to be billed for anything.  Better to collect up front, or to tell them up front "Medicare will pay this, and your supplemental will pay that".  And you look like a star when you know your stuff.

Also, our JMAC has a great site that you can look right at the time of service and see if they've met their deductible.  (This year it's $147.00)  I have a few patients with no supplemental so I know what to collect and I can tell them "as of right now, you haven't met your deductible".

kristin

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One thing I will add to the discussion about collecting deductibles upfront, and this is for the OP...if you do decide to do that, you had better be sure you are submitting your claims that same day, and that they are "clean" claims.

I don't collect Medicare deductibles upfront, and every year, I have at least five patients whose deductible we meet, and we bill them, and then they call and say that they already paid their deductible upfront at Dr. So and So's office, so why am I billing them for something they already paid? 

Trying to explain to an elderly patient (who does not understand deductibles in the first place) that Dr. So and So may have taken their money upfront, but my doctor's claim was processed first, and that they need to get their money back from Dr. So and So is not fun for me. Somehow, I end up looking like the bad guy for billing them, and NOT Dr. So and So's office who took money upfront, and didn't submit the claim right away. Argh...