Medicare and Affiliated Products

MEDICARE AND AFFILIATED PRODUCTS:

There exists some confusion, both by the practice and by the patient, as to what Medicare or other Medicare related benefits a person may have. While this document will not solve all of the issues, we believe that some background information may be of use to you.

Medicare: If a patient has classic Medicare, a few rules apply. First, Medicare does have conservative therapy mandates now of compression stockings having been worn (at any time in the past) for ninety days or more. Second, the patient may have a Medicare deductible. Third, the patient will be subject to the 20 percent co-insurance.

You have to be accepting Medicare patients and the practice has to be contracted with Medicare. It is a good idea to make sure the physician is properly ‘linked’ to the practice or you can have some claims difficulties.

Medicare Advantage: This is NOT Medicare per se. The patient’s Medicare is replaced by a commercial plan. PacifiCare’s Secure Horizon’s is a classic example of a Medicare replacement plan. If you see a patient card that has the word Advantage on it or the patient is of Medicare age and is presenting what looks like a commercial insurance card, you should be aware of the following:
a. You must be contracted with that payer
b. You almost always have to preauthorize the services
c. You will almost always have to submit notes and a letter of medical necessity (even if preauthorized).
d. The patient may have a deductible, copayment or even a coinsurance that will need to be collected.

Medicare Supplemental: The patient’s primary insurance is still Medicare. These types of policies cover the deductible and coinsurance that classic Medicare leaves as the patient’s responsibility. Almost all of these plans cover the patient responsibility portion up to 100% of the Medicare allowable amount. You do not have to be contracted with these various Supplemental plans. If the patient has informed Medicare, the secondary plan should be automatically notified by Medicare (commonly called ‘crossover’) when a claim is adjudicated. It is essential to review your Medicare Explanations of Payments (EOP) to ensure the crossover was completed. If not, you will need to bill the Supplemental plan directly with a copy of the Medicare EOP. Examples of this type of plan are the United Health Care AARP Plan and Mutual of Omaha’s Supplement Plan.

Commercial Insurance: Some Medicare patients still have a standard commercial plan as their secondary insurance. Like a Supplemental plan, you do not have to be contracted in order to bill for the patient’s deductible or coinsurance. However, unlike a Supplemental plan, there is no guarantee that the patient’s Medicare deductible or coinsurance will be paid as the Commercial Insurance plan may have a deductible, copayment or coinsurance to which the patient is still liable. Patient’s can be quite adamant and agitated when their secondary insurance does not act like a Supplemental plan.

It is no wonder some of our seniors are a bit confused when it comes to Medicare and the various products out there. Many times the patient does not realize they have signed up for a Medicare Advantage plan which can sometimes severely limit the physicians they may see.

Please call me if you have any questions regarding the above or any other questions.

Yrs.

AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts719.233.0099 www.apfsbilling.com