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medicare

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rdmoore2003:
I have a pt that came to us with medicare.   I sent claim and was denied stating not payable due to pts workers compensation settlement.   Medicare is stating that have to refile with claim stating "not workers compensation related"      we do not have any information in our system on his w/c claim, so how could i mark this on the claim and the other issue is that when refiled to clearinghouse, medicare is denying for duplicate.   call medicare, get a different answer by each person but then person transfers to another person which gives a different answer than the last, transfers etc, etc, etc,

DMK:
Some patients who settle their W/C claims have a "Medicare set aside".  These are funds that the patient was given to pay for medical care for particular conditions related to their W/C case.  The patient SHOULD have this information, such as WHAT BODY PART WAS INJURED AND WHAT WAS INCLUDED IN THE W/C CASE.  They should have a copy of their settlement.

We had a case like this (we are a chiropractic office).  We had to bill the patient (not Medicare) until the set aside money was exhausted.  Then when we began to bill Medicare we had to have the patient call and provide the records showing that the set aside fund were exhausted.

The patient will have to provide the information, be a good accountant, and be pro-active.

If your doctor's care had NOTHING to do with the W/C case, the diagnosis should be for care unrelated to the W/C case.

rdmoore2003:
the diagnosis does not have anything to do with the w/c case.   this is the problem I am having.   Is there maybe a modifier to use?   we have no information on w/c information due to the patient was seen for services that were not w/c related.

DMK:
The patient needs to pick up the phone and get Medicare sorted out if they want their Medicare to pay.  The doctor or staff or the biller (you?) will have to explain that to the patient.  This won't be the last time they have difficulty using their Medicare benefits if they don't sort it out immediately.

Michele:
That's weird.  I've only had this problem when it was based on the diagnosis.

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