Medicare- "Participating providers" -RESPONSES

Medicare- "Participating providers" -RESPONSES

Randall McFarland, CPO

Thank you to all who responded to the following
ORIGINAL QUESTION
I think it is unfair that we, as providers, are expected to provide services
without knowing that our fees will be paid by Medicare. Kathy Dodson
explained to me that the ability to verify eligibility is a benefit of being
a participating provider. (A provider who agrees to accept assignment for
all services provided to Medicare beneficiaries).
   If you are a participating provider, would you please share your
experience as to the advantages of being a participating provider? Are you
able to determine if a client is currently eligible for benefits for our
services and are you able to determine if a particular service will be
covered before it is provided?
   I'll share the responses with the list and won't include names.
Randy McFarland,CPO

RESPONSES (each separated by a blank line)
We are a participating provider. Medicare will only tell us if the patient
is Medicare eligible and the patient must give Medicare their permission
for Medicare to disclose this bit of info.
     Medicare has never preauthorized a service. They always state the
claim will be considered when received.
     Medicare will tell you certain items are not a covered benefit,
compression hose, foot orthoses, etc.
    Also - with the patient's permission, you can find out if same or similar
has been filed and when, which helps you calculate if MCare is going to pay
for the service again.
    In general, MCare is the easiest to get paid on.

My question is why AOPA is not addressing this. I would be happy to give
them their 300 bucks to join if they could show me any concrete results from
their efforts.This is something that all of us as individuals are very
concerned about but haven't a clue on how to fix. Has anyone from the list
serv offered a suggestion which would involve us all as a team?

We are participating and bill Region B DMERC. The only benefit I have found
is that we are able, via the electronic billing software they provide, to
determine if a patient has coverage (sometimes, if the coverage is through a
Medicare HMO), and if their annual deductibles have been met. As far as I
can tell, there is no way to determine if a particular device/code will be
covered for a particular patient (i.e., if they are eligible or have already
received same or similar recently).

I have had this discussion before with several other listers. Here in DMERC
A, if you are a participating provider, you can sign up for a secure network
that allows you to check Medicare B eligibility. In addition, and this is
very useful, it will also tell you if the beneficiary has a Medicare HMO.
As you probably already know, the bene's rarely, if ever, know that they are
enrolled in some Medicare HMO that is primary to any other coverage. It
only took one case such as that to make us become participating suppliers.

We had been a participating provider with Medicare for years, and contrary to
Medicare's sales pitch, there were never any advantages. Unlike physician
services, Medicare states O&P eligibility information can only be given to
the patient and not the provider. We would have the patient contact Medicare
by phone in our presence, and with their permission, Medicare would then
speak to us and explain general benefits...but never for individual
procedures.
I have now become a non-par provider. The process is still the same, no
difference.
    The advantage? We now accept assignment for what and when we choose. Now
with the new rules governing determination, eligibility, replacement,
previous provision of services by another provider during the 3-5 year time
period, and all the other BS, it is very easy to not get paid! (I've
actually had Medicare take back payments causing months and months of
appeals, because therapists or rehab.depts. have lost the patient's device
while under their care.) Explain the idiotic logic of this!!!!
    Also, it's a shock to provide a TLSO and have Medicare reject it, only to
find out a similar device (LS corset) was provided the year before from
another facility or hospital.
    If it is difficult for a patient to provide initial payment, we will work
with them....receive a deposit or partial payment to begin services, and then
immediately bill Medicare as non-assignment . Seniors are great, when they
receive payment they almost always turn it over to the office the same day.
If we want to accept assignment, we have the option. So far, the process is
working well.
    Thanks for bringing up this subject. These are not isolated problems and
are common complaints among many facilities.

I don't know the answer to that, Randy. I also do not understand why
Medicare and other 3rd party payors cannot provide definitive answers on
whether or not we will be paid BEFORE services are rendered. I just ate a
pair of shoes (custom) because the patient had already gotten shoes that she
was dissatisfied with from another company. I guess we just keep rolling the
dice.

I also have a problem with this concept. I would love to take my car to a
mechanic for repairs or a new item. Wait for him to finish. Then decide
whether I should pay him for the work or not. Maybe I'll only pay for the
new radiator, but not the hoses needed to connect it. I am a Certified
prosthetist in the field now over 8 years and I have seen time and again how
we bill medicare in hopes that they will fully reimburse us (80% usually). I
work with many Bi-Lateral amputees and have on several occasions, with
correct coding, has the left foot denied, but the right one approved. If the
patient has no feet and we provide him with the same foot for both sides,
why on god's earth would they only approve one?!! Just recently, I had a
transfemoral patient. I billed medicare for the prosthesis and they denied
the knee. It was an OttoBock 3R49 Safety Knee for functional levels 1 and
up. The patient is geriatric and the knee was denied because not medically
necessary. Go figure. I finally got paid after fighting with them for
almost 3 months. They of course gained 3 months of interest in their bank
accounts. The Only way to verify eligibility is to see if his current
medicare card is active. This can be done with a phone call, but if the date
is current, you don't need to.

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