Medicare frustrations- Responses
Randall McFarland, CPO
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Medicare frustrations- Responses
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Randall McFarland, CPO
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Hi Listmembers-
Verification of coverage
Stephan R. Manucharian, CP recently asked if there was a way to verify
Medicare coverage. I remember almost a year ago an announcement that we would
be able to do just that, but I've heard nothing of this concept since. How
are we to know if we can provide services to someone who may have received
similar care recently or just received an electric wheelchair particularly if
he hasn't told us about it? How can we tell in advance if a shoe attached to
an AFO will be covered?
Further, we recently received a denial for services rendered to a
Medicare patient because his coverage had temporarily lapsed during the DOS.
This patient didn't tell us that coverage had lapsed and I don't know if he
was notified or not. He has no money. We had provided services prior and
received payment and to my knowledge, there is no way to verify current
eligibility with Medicare.
Serial denials
Medicare has a habit of issuing multiple denials on a claim. For instance,
they'll deny for one reason and when we accommodate and resubmit the claim,
we will receive a denial for a completely different reason. This policy is an
obvious stalling tactic. Do they think we'll just give up after the first
denial? Why don't they look for all the possible reasons for denial while
they have it in their hands the first time? Do they get paid for each time
they handle a claim? It will save everyone much time and effort if Medicare
was required to disclose ALL reasons for denial of the claim in question.
Have you experienced this?
We can continue to submit to the risk of providing services without
assurance that we'll be paid, but this only perpetuates an unfair situation.
What can we do? Because Medicare policy is determined by Congress, I
suppose that until policy is changed, Medicare will refuse to go the extra
effort or providing preauthorization or verifying coverage. Let's ask our
lobbyists for direction as to best affect a change in Medicare laws so we can
verify coverage and obtain ALL reasons for denial at once.
Will those knowledgeable on this get back to me with information about
what we can do as a group? I need specifics here, and I'll get back to the
list with the responses.
Randy McFarland, CPO
RESPONSES- each separated by a blank line
As you well know Medicare providers have a choice of accepting assignment or
not.
It had been my impression that you were less likely to get business if
you did
not accept assignment because the patient would have to pay the difference
between the U&C of the provider and what M/C allows....as well as their 20%.
I
have since been made aware that you have the choice of not accepting
assignment (do not check the box on the 1500 form that states you accept
assignment) and
still treat the majority of you standard payable claims as if they were an
assigned item. If the problem claims you have with M/C are with the same set
of L
codes, i.e. shoes attached to braces....repairs etc...and this is a small
percentage of your total business......then choose to not accept assignment
on
the small percentage of claims you anticipate will be held up or denied. This
of
course should be discussed with the patient in advance....and they usually
understand when you tell them that you choose not to accept assignment with
Medicare on this particular claim because of the historical denials you have
received in the past. Let the patient know that as a courtesy, you treat
the
majority of M/C billings as if you accepted assignment and have not billed
the
patient for the difference between the allowed amount and your U&
C.......except
on the small percentage of problem claims that you never get paid for and
have
to write off as a loss.
In fact you still submit the unassigned claims that pose you no
problems to
M/C, with the exception of the few problem claims you have historically
encountered. Thus you inform the patient that you will treat his potential
problem claim as truly an unassigned claim. The patient is responsible for
payment in full to you the provider at the time of service and that the
patient
will have to submit the claim to M/C himself for reimbursement...and fight it
out
with M/C for payment.(This is discussed with the patient at the beginning of
the
assessment so the patient does not feel as if he was setup.
Of course you can still accept assignment of potential problem
claims.......bill
medicare yourself....but put the modifier code that you have reason to
believe
that M/C will deny this claim. You need to get the signature of the patient
and
report to him the cost of the service you are providing so he is not in shock
when the bill comes...if M/C denied payment.
Please let me know if this makes sense.....if you think I am crazy or if
you
disagree. The responsibility of claims being denied should not be all born on
the
brunt of the provider...especially when M/C has not offered any tangible way
to
pre-approve services. The patient must be employed and made aware of the
problem claims and be held equally responsible.
Concerned that the patient will go across the street to Joe competition
who
accepts assignment? If your service and care is excellent.......people are
happy
to pay if they know that you are eating it on certain items.
Karl Lindborg CPO
In our Region A, if you sign a participating Medicare supplier agreement
with the DMERC, you will then be able to sign on to a secure network and get
information on the beneficiary such as when they became eligible for
Medicare B benefits; whether they met their deductible for the year; and
most importantly, whether or not they belong to a Medicare HMO and the name
of the HMO. This is not located on the DMERC website as Stephan thought. I
know Stephan personally and have discussed this with him at length. At your
convenience, give my office a call 718 748 4806 and speak to Pat. She will
be able to give you information specific to our DMERC, HealthNow. Your
DMERC may not have this ability. (I think you are from California??)
With respect to serial denials, I am not absolutely sure, but I think
that
once the claim fails for any reason, it gets kicked out without going any
further through the system, so that if there are other errors, they won't be
picked up the first time around. If you are billing electronically, some
software actually pretests each claim before it submission so that you can
clear up any discrepancies from jump city and then send a completely clean
claim.
Providing services with expectation of reimbursement without assurances
from
Medicare should not be an issue as long as a few steps are followed:
* Medical necessity is determined
* Use listed L codes w/ fees
* All documentation is in order
* If coverage is uncertain, without fail, make sure the beneficiary signs a
waiver stating they know the service/device may not be covered and that they
will be liable for payment.
Eric Schwelke, C.P.O
I am in Wash DC this week meeting with some of our favorite CMS people
about topics like you have raised. I am sure the listserve is aware of the
recent GAO audit criticizing the Medicare contractors because their people
could not answer simple questions asked directly from their own website FAQ
areas.
The issues you raise go deeper. 35% of all denied claims are never
resubmitted! Over 60% of all claims denied twice are never resubmitted. The
contractors know this and are using it against us. The first thing we must
all do, is be vigilant in resubmissions.
The second is to take advantage of a little known fact. If you call
Medicare with the patient sitting in the office, on the phone with you, they
will answer the questions you need the answers to. That is and will continue
to be the only way to get the info you need.
HIPAA will force better access to Medicare eligibility info, but if you
use Region C's system it is pretty good right now. But as you pointed out,
this will not stop the like item denials and such. But it will show current
coverage.
I will try to raise these issues tomorrow in my meetings and get you some
feedback.
Pat Shannon, President
Healthcare Management Solutions
Hi Listmembers-
Verification of coverage
Stephan R. Manucharian, CP recently asked if there was a way to verify
Medicare coverage. I remember almost a year ago an announcement that we would
be able to do just that, but I've heard nothing of this concept since. How
are we to know if we can provide services to someone who may have received
similar care recently or just received an electric wheelchair particularly if
he hasn't told us about it? How can we tell in advance if a shoe attached to
an AFO will be covered?
Further, we recently received a denial for services rendered to a
Medicare patient because his coverage had temporarily lapsed during the DOS.
This patient didn't tell us that coverage had lapsed and I don't know if he
was notified or not. He has no money. We had provided services prior and
received payment and to my knowledge, there is no way to verify current
eligibility with Medicare.
Serial denials
Medicare has a habit of issuing multiple denials on a claim. For instance,
they'll deny for one reason and when we accommodate and resubmit the claim,
we will receive a denial for a completely different reason. This policy is an
obvious stalling tactic. Do they think we'll just give up after the first
denial? Why don't they look for all the possible reasons for denial while
they have it in their hands the first time? Do they get paid for each time
they handle a claim? It will save everyone much time and effort if Medicare
was required to disclose ALL reasons for denial of the claim in question.
Have you experienced this?
We can continue to submit to the risk of providing services without
assurance that we'll be paid, but this only perpetuates an unfair situation.
What can we do? Because Medicare policy is determined by Congress, I
suppose that until policy is changed, Medicare will refuse to go the extra
effort or providing preauthorization or verifying coverage. Let's ask our
lobbyists for direction as to best affect a change in Medicare laws so we can
verify coverage and obtain ALL reasons for denial at once.
Will those knowledgeable on this get back to me with information about
what we can do as a group? I need specifics here, and I'll get back to the
list with the responses.
Randy McFarland, CPO
RESPONSES- each separated by a blank line
As you well know Medicare providers have a choice of accepting assignment or
not.
It had been my impression that you were less likely to get business if
you did
not accept assignment because the patient would have to pay the difference
between the U&C of the provider and what M/C allows....as well as their 20%.
I
have since been made aware that you have the choice of not accepting
assignment (do not check the box on the 1500 form that states you accept
assignment) and
still treat the majority of you standard payable claims as if they were an
assigned item. If the problem claims you have with M/C are with the same set
of L
codes, i.e. shoes attached to braces....repairs etc...and this is a small
percentage of your total business......then choose to not accept assignment
on
the small percentage of claims you anticipate will be held up or denied. This
of
course should be discussed with the patient in advance....and they usually
understand when you tell them that you choose not to accept assignment with
Medicare on this particular claim because of the historical denials you have
received in the past. Let the patient know that as a courtesy, you treat
the
majority of M/C billings as if you accepted assignment and have not billed
the
patient for the difference between the allowed amount and your U&
C.......except
on the small percentage of problem claims that you never get paid for and
have
to write off as a loss.
In fact you still submit the unassigned claims that pose you no
problems to
M/C, with the exception of the few problem claims you have historically
encountered. Thus you inform the patient that you will treat his potential
problem claim as truly an unassigned claim. The patient is responsible for
payment in full to you the provider at the time of service and that the
patient
will have to submit the claim to M/C himself for reimbursement...and fight it
out
with M/C for payment.(This is discussed with the patient at the beginning of
the
assessment so the patient does not feel as if he was setup.
Of course you can still accept assignment of potential problem
claims.......bill
medicare yourself....but put the modifier code that you have reason to
believe
that M/C will deny this claim. You need to get the signature of the patient
and
report to him the cost of the service you are providing so he is not in shock
when the bill comes...if M/C denied payment.
Please let me know if this makes sense.....if you think I am crazy or if
you
disagree. The responsibility of claims being denied should not be all born on
the
brunt of the provider...especially when M/C has not offered any tangible way
to
pre-approve services. The patient must be employed and made aware of the
problem claims and be held equally responsible.
Concerned that the patient will go across the street to Joe competition
who
accepts assignment? If your service and care is excellent.......people are
happy
to pay if they know that you are eating it on certain items.
Karl Lindborg CPO
In our Region A, if you sign a participating Medicare supplier agreement
with the DMERC, you will then be able to sign on to a secure network and get
information on the beneficiary such as when they became eligible for
Medicare B benefits; whether they met their deductible for the year; and
most importantly, whether or not they belong to a Medicare HMO and the name
of the HMO. This is not located on the DMERC website as Stephan thought. I
know Stephan personally and have discussed this with him at length. At your
convenience, give my office a call 718 748 4806 and speak to Pat. She will
be able to give you information specific to our DMERC, HealthNow. Your
DMERC may not have this ability. (I think you are from California??)
With respect to serial denials, I am not absolutely sure, but I think
that
once the claim fails for any reason, it gets kicked out without going any
further through the system, so that if there are other errors, they won't be
picked up the first time around. If you are billing electronically, some
software actually pretests each claim before it submission so that you can
clear up any discrepancies from jump city and then send a completely clean
claim.
Providing services with expectation of reimbursement without assurances
from
Medicare should not be an issue as long as a few steps are followed:
* Medical necessity is determined
* Use listed L codes w/ fees
* All documentation is in order
* If coverage is uncertain, without fail, make sure the beneficiary signs a
waiver stating they know the service/device may not be covered and that they
will be liable for payment.
Eric Schwelke, C.P.O
I am in Wash DC this week meeting with some of our favorite CMS people
about topics like you have raised. I am sure the listserve is aware of the
recent GAO audit criticizing the Medicare contractors because their people
could not answer simple questions asked directly from their own website FAQ
areas.
The issues you raise go deeper. 35% of all denied claims are never
resubmitted! Over 60% of all claims denied twice are never resubmitted. The
contractors know this and are using it against us. The first thing we must
all do, is be vigilant in resubmissions.
The second is to take advantage of a little known fact. If you call
Medicare with the patient sitting in the office, on the phone with you, they
will answer the questions you need the answers to. That is and will continue
to be the only way to get the info you need.
HIPAA will force better access to Medicare eligibility info, but if you
use Region C's system it is pretty good right now. But as you pointed out,
this will not stop the like item denials and such. But it will show current
coverage.
I will try to raise these issues tomorrow in my meetings and get you some
feedback.
Pat Shannon, President
Healthcare Management Solutions
Citation
Randall McFarland, CPO, “Medicare frustrations- Responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 8, 2024, https://library.drfop.org/items/show/217738.
