Billing > Billing
Billing Medicare when out of network
Merry:
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:
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.
RichardP:
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.
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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.)
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