Author Topic: Medicare  (Read 592 times)

ste

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Medicare
« on: July 05, 2017, 01:00:37 PM »
We all know that if Medicare is primary and Medicare does not recognize the specialty then the secondary needs to pay as if they were primary. Writing a letter and sending to the insurance stating this fact which is a part of Medicare guidelines has always coaxed the insurance into paying.

I've run into a problem with BCBS of New Jersey where they do not want to see a letter from me. They want the letter to come directly from Medicare. The local is Regence and all interaction with the home plan is through them.

I've gone through level 1,  then reached out to the provider services rep, and thirdly contacted a supervisor at Blue Card. All three were confident and exited to take on the challenge but ultimately all 3 came back with the same answer. Have the rules changed recently? Is it even possible to obtain such a letter from Medicare without ever submitting a claim to them? 

Michele

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Re: Medicare
« Reply #1 on: July 05, 2017, 01:23:52 PM »
If the provider is a Medicare provider and it's simply for a non covered service then yes, you can obtain a denial.  However, if it is a specialty that Medicare does not enroll then no, you cannot submit to get a denial.  We have gone thru this in the past.  For example, Medicare does not cover acupuncture and does not enroll acupuncturists.  So if the provider is an MD who also is an acupuncturist (we have that) then the claim can be submitted and Medicare will send a denial.  BUT if the provider is only an acupuncturist then they cannot enroll in Medicare and therefore cannot submit a claim for a denial. 

It sounds like you've done everything right but still are hitting a brick wall.  I believe the issue is with BCBS though.  They have to accept the fact that if the provider is not enrolled in Medicare because Medicare does not enroll that provider type then there is no way for you to obtain the information from Medicare.  It's not like a commercial carrier where you can submit the claim even if the provider is not enrolled and get something stating it's not covered.
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ste

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Re: Medicare
« Reply #2 on: July 08, 2017, 05:05:43 AM »
The provider is a naturopath. There is no MD or any other specialty involved. Just naturopathy.  Medicare does not enroll naturopaths. And yes we have been through this before. What makes this case a first is that when the home plan actually has a letter from me in their hand stating the relevant Medicare Guideline they reject it saying the letter must come from Medicare and not me.

Our local Blue is Regence and the home plan is BCBS of New Jersey. I cannot follow up on claims or appeal claims from the home plan without going through Blue card. Blue card tells me I have exhausted all methods of appeal. Although Blue card does not agree with the home plan they say there is nothing more they can do. The home plan is standing firm in saying a letter must come from Medicare stating that if Medicare is primary and the provider is a specialist not enrolled by Medicare then the secondary insurance must process the claim as if they were the primary insurance.

Where can I turn next?

   

Michele

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Re: Medicare
« Reply #3 on: July 10, 2017, 09:44:45 AM »
You are in a tough spot.  Everybody knows that Medicare doesn't enroll naturopaths, but where to get it in writing.  I did a search and found this:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Enrollment_Eligibility_Reference_Table.pdf 

It does state that Medicare does not enroll Naturopaths.  Maybe that will help.  I would also include the copy of covered provider types from the Medicare Enrollment application:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Enrollment_Eligibility_Reference_Table.pdf 

Page 8 & 9.

Hopefully these two references will be adequate.

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PMRNC

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Re: Medicare
« Reply #4 on: July 13, 2017, 08:00:26 AM »
Quote
We all know that if Medicare is primary and Medicare does not recognize the specialty then the secondary needs to pay as if they were primary

I'm not a Medicare expert at all but the above statement may not be entirely true. My dad has Medicare Primary and his secondary does cover acupuncture but it depends ON The provider. If the provider doing the acupuncture cannot be a Medicare provider, his secondary is going to deny it as a non covered provider. He too went through same thing so he had to find a chiropractor to do his acupuncture and then his secondary would pay.

Linda Walker
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ste

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Re: Medicare
« Reply #5 on: July 25, 2017, 07:16:55 AM »
2 important additions

1. The home plan has made it clear that the letter must come directly from Medicare. A letter from me with attachment of Medicare rules from the Medicare web site is not acceptable.
2. Blue Card, the middle men in all this, have made it clear that I have exhausted all opportunities to communicate with the home plan and get this issue resolved. Hence my ending statement in the second post, Where can I turn next?

I have filed a complaint with the Oregon Insurance Commissioner's office but have yet to hear back from them

   

PMRNC

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Re: Medicare
« Reply #6 on: July 25, 2017, 08:20:29 AM »
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I have filed a complaint with the Oregon Insurance Commissioner's office but have yet to hear back from them

Unless this is govt/church plan OR an individual plan with BCBS the State dept of insurance is not going to be able to do anything. Group health plans that are not govt/church are ERISA plans and therefore subject to Dept of Labor. IF this is an ERISA plan than you can file an appeal with them showing them that Medicare does not enroll nor accept claims from your provider. (use the links Michele posted earlier). Meanwhile you can make SURE it's a covered service under the patient's plan by asking for a copy of their summary plan benefit and make a copy of it. YOU might STILL be out of luck if the secondary does not cover the services or the provider, that's why you really need to make sure you have the SPB in your hands, again, IF this is an ERISA policy.
Linda Walker
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