Sunday, June 28, 2015

Medicare non covered items and services - part 2


 (2) Non-Covered Items and Services
A) Custodial Care
Custodial care furnished in the beneficiary’s home or an institution is not covered. Custodial care is
personal care that does not require the continuing attention of trained medical or paramedical
personnel and serves to assist an individual in the activities of daily living. The following activities are
considered custodial care:
• Walking;
• Getting in and out of bed;
• Bathing;
• Dressing;
• Feeding;
• Using the toilet;
• Preparing a special diet; and
• Supervising the administration of medication that can usually be self-administered.
Individual reasonable and necessary services may be covered under Part B even though Part A denies coverage of a beneficiary’s overall hospital or SNF stay because it is determined to be
custodial.Care furnished to a beneficiary who has elected the hospice care option is considered custodial only if it is not reasonable and necessary for the palliation or management of the terminal illness and related conditions.

B) Cosmetic Surgery
Cosmetic surgery and expenses incurred in connection with cosmetic surgery are not covered.
Cosmetic surgery includes any surgical procedure directed at improving the beneficiary’s appearance.

The prompt (as soon as medically feasible) repair of an accidental injury or the improvement of the
functioning of a malformed body member are covered. Some examples include:
• Surgery performed in connection with the treatment of severe burns;
• Surgery to repair the face following a serious automobile accident; and
• Surgery for therapeutic purposes that may coincidentally also serve some cosmetic purpose.

C) Items and Services Furnished by the Beneficiary’s Immediate Relatives and Members
of the Beneficiary’ s Household

Payment for items and services furnished by the beneficiary’s immediate relatives and members of
the beneficiary’s household will not be made since these items and services are ordinarily furnished
gratuitously because of the relationship between the beneficiary and the provider or supplier.
The following items and services will also not be paid:
• Charges for services furnished by a related physician or supplier that are submitted by an unrelated individual, partnership, or professional corporation; and
• Those services furnished incident to a physician’s professional service when the ordering or supervising physician has a prohibited relationship to the beneficiary.

A professional corporation is:
• Completely owned by one or more physicians or is owned by other health care professionals as authorized by State law; and
• Operated for the purpose of conducting the practice of medicine, osteopathy, dentistry,
podiatry, optometry, or chiropractic.

Any physician or group of physicians that is incorporated constitutes a professional corporation. Items and services furnished by non-physician suppliers that have a prohibited relationship with the beneficiary and are not incorporated will not be paid, regardless of whether the supplier is owned by a sole proprietor who is related to the beneficiary or owned by a partnership in which one of the partners is related to the beneficiary. This payment restriction applies only to professional corporations, regardless of the beneficiary’s relationship to any of the stockholders, officers, or directors of the corporation or to the individual who furnished the service.
A beneficiary’s immediate relatives include the following degrees of relationship:
• Husband and wife;
• Natural or adoptive parent, child, and sibling;
• Stepparent, stepchild, stepbrother, and stepsister;
• Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
• Grandparent and grandchild; and
• Spouse of grandparent or grandchild.
If the marriage upon which a step- or in-law relationship is based becomes terminated through
divorce or death, the prohibited relationship will continue to exist.
Members of the beneficiary’s household include the following who share a common abode with him
or her as part of a single family unit:
• Individuals who are related by blood, marriage, or adoption;
• Domestic employees; and
• Other individuals who live together as part of a single family unit (does not include roomers or boarders).

D) Dental Services

Items and services that are furnished in connection with the care, treatment, filling,removal, or replacement of teeth or the structures directly supporting the teeth are not covered. The structures that directly support the teeth are the periodontium, which includes:
• The gingivae;
• The dentogingival junction;
• The periodontal membrane;
• The cementum; and
• The alveolar process.
Whether or not the beneficiary is hospitalized has no direct bearing on if payment will be made for a
given dental procedure.

Some dental services may be covered depending upon whether the primary procedure that the
dentist performs is covered. For example, the following services are covered:
• An x-ray that is taken in connection with the reduction of a fracture of the jaw or facial bone; and
• A tooth extraction that is performed to prepare the jaw for radiation treatments of neoplastic disease.

I)Non-Physician Services Furnished to Hospital and Skilled Nursing Facility Inpatients That Are Not Provided Directly or Under Arrangement
In general, non-physician services furnished to Part A and Part B hospital inpatients and Part A
SNF inpatients that are not provided directly or under arrangement are not covered.
The following are covered:
• Physician services furnished to hospital and SNF inpatients (with the exception of therapy,
which must be provided by the SNF);
• Physician assistant services;
• Nurse practitioner services;
• Clinical nurse specialist services;
• Certified nurse-midwife services;
• Qualified clinical psychologist services; and
• Certified registered nurse anesthetist services.
The following Part A SNF inpatient services may be covered if they are not provided directly or under arrangement and are furnished by an authorized provider or supplier:
• Home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies (including related necessary ambulance services);
• Epoetin Alfa (EPO);
• Hospice care related to a beneficiary’s terminal condition;
• Radioisotope services;
• Some customized prosthetic devices;
• Some chemotherapy and chemotherapy administration services; and
• The following services that are considered beyond the scope of a SNF when furnished in a participating hospital or Critical Access Hospital, including ambulance services related to such services (does not apply to services furnished in an Ambulatory Surgical Center):
◦ Cardiac catheterization;
◦ Computerized axial tomography scans;
◦ Magnetic resonance imaging;
◦ Ambulatory surgery that involves the use of an operating room;
◦ Radiation therapy; and
◦ Emergency services.

E) Certain Foot Care Services and Supportive Devices for the Feet
The following foot care services and devices are generally not covered, except as described below
under Exceptions:
• Treatment of flat foot;
• Routine foot care, which includes:
◦ The cutting or removal of corns and calluses;
◦ The trimming, cutting, clipping, or debriding of nails;
◦ Other hygienic and preventive maintenance care (for example, cleaning and soaking the feet, use of skin creams to maintain skin tone of either ambulatory or bedridden patients, and any other
service performed in the absence of localized illness, injury, or symptoms involving the foot); and
◦ Orthopedic shoes and other supportive devices for the feet.
The following devices and services are covered:
• Orthopedic shoes that are an integral part of a leg brace;
• Therapeutic shoes furnished to diabetics;
• Services that are a necessary and integral part of an otherwise covered service (for example, the diagnosis and treatment of ulcers, wounds, or infections);
• Treatment of warts on the foot (including plantar warts);
• Treatment of mycotic nails as follows:
◦ For an ambulatory beneficiary, the physician attending the mycotic condition must document that:
▪ There is clinical evidence of mycosis of the toenail; and
▪ The beneficiary has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
◦ For a non-ambulatory beneficiary, the physician attending the beneficiary’s mycotic condition must document that:
▪ There is clinical evidence of mycosis of the toenail; and
▪ The beneficiary suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
• Presence of a systemic condition such as one of the following metabolic, neurologic, and peripheral vascular diseases (this is not an all-inclusive list):
◦ Diabetes mellitus;*
◦ Arteriosclerosis obliterans;
◦ Buerger’s disease;
◦ Chronic thrombophlebitis;* and
◦ Peripheral neuropathies that involve the feet:
▪ Associated with malnutrition and vitamin deficiency:*
▫ Malnutrition (general, pellagra);
▫ Alcoholism;
▫ Malabsorption (celiac disease, tropical sprue); and
▫ Pernicious anemia;
▪ Associated with carcinoma;*
▪ Associated with diabetes mellitus;*
▪ Associated with drugs and toxins;*
▪ Associated with multiple sclerosis;*
▪ Associated with uremia (chronic renal disease);*
▪ Associated with traumatic injury;
▪ Associated with leprosy or neurosyphilis; and
▪ Associated with hereditary disorders:
▫ Hereditary sensory radicular neuropathy;
▫ Angiokeratoma corporis diffusum (Fabry’s); and
▫ Amyloid neuropathy.
*For Medicare to cover routine procedures for this condition, the beneficiary must be under the active care of a MD or a DO who has documented the condition.

F) Investigational Devices
Category A devices, as categorized by the U.S. Food and Drug Administration, are considered
not medically reasonable and necessary and are therefore not covered.

Category B devices may be covered if they are considered medically reasonable and necessary
and all other applicable Medicare coverage requirements are met.

G) Services Related to and Required as a Result of Services That Are Not Covered
Medical and hospital services that are related to and required as a result of services that are not covered will not be paid. Some examples of these services are:
• Cosmetic surgery;
• Non-covered organ transplants; and
• Services related to follow-up care or complications that require treatment during a hospital stay in which a non-covered service is performed.

When a beneficiary is hospitalized for a non-covered service and requires services that are not related to the non-covered service, the unrelated services are covered. For example, if a beneficiary breaks a leg while he or she is in the hospital for a non-covered service, the services to treat the broken leg are covered since they are not related to the non-covered service.

When a beneficiary is discharged from a hospital stay in which he or she receives non-covered
services and subsequently requires services to treat a condition or complication that arose as a
result of the non-covered services, reasonable and necessary medical or hospital services may be
covered. Some examples include:
• Repair of complications after transsexual or cosmetic surgery; and
• Treatment of an infection at the surgical site of a non-covered service.
Any subsequent services that could be incorporated into a global fee are considered paid in the global fee and will not be paid again.

Wednesday, June 17, 2015

Medicare as secondary payer - Full details

When Medicare As Secondary Payer

Until 1980, Medicare was the primary payer for all Medicare covered services except for services covered by workers' compensation or black lung benefits or paid for by the Department of Veterans Affairs or other government entities. Since 1980, a series of changes in the Medicare law has shifted costs from the Medicare program to private sources of payment. Presently, Medicare is the secondary payer for individuals:
  • Who are aged 65 or older and currently working with coverage under an employer-sponsored or employee organization (such as a union) group health plan.
  • Who are aged 65 or older and are covered by a working spouse's employer group health plan or employee organization (such as union) group health plan.
  • Who are under age 65, disabled, and are covered by a large group health plan due to their own or other family member's current employment status.
  • With kidney failure. Medicare is the secondary payer during the Coordination of Benefits (COB) period if they have coverage
  • under their own, a spouse's, or other family member's employer-sponsored or employee organization group health plan.
  • Who receive services covered under Workers' Compensation, Federal Black Lung, automobile, no-fault, or liability insurance plans.
  • Who receive services covered under the Veteran Administration.
a. Working Aged

Medicare is secondary payer for individuals aged 65 or older who are currently working and have coverage through an Employer Group Health Plan (EGHP). Medicare is also secondary if the beneficiary has coverage through an employed spouse of any age. In order to meet the Working Aged provision, the employer must have at least 20 employees working for the company. At times, 2 or more smaller employers combine to provide coverage. As long as at least 1 employer has 20 or more employees, the requirement is met.
Medicare is primary in the following situations:
Individuals who are enrolled in Medicare Part B only.
Individuals enrolled in Medicare Part A on the basis of a monthly premium.
EGHP plans where there is less than 20 employees and the employer does not combine with another employer with more than 20 employees.
Individuals covered by a health plan that is not provided by Group Health Plan (GHP). An example would be a plan that is purchased by an individual privately rather than through a group plan.
A plan provided through retirement resulting from past employment. For Medicare to be secondary, the coverage must be the result of current employment status. The Medicare beneficiary may be retired and have retiree coverage. If the spouse is still employed and provides coverage, this coverage will be primary to Medicare.
a.1 Vow of Poverty Provision
The Omnibus Budget Reconciliation Act of 1993 makes an exemption from MSP provisions for members of a religious order who have taken a vow of poverty retroactive to 1981. Employers must certify that an individual has taken a vow of poverty. Medicare is then considered the primary payer for such individuals, (i.e., nuns, priests, etc.)

b. Disability
Effective August 10, 1993, Medicare is secondary payer for individuals under age 65 who are entitled to Medicare due to disability and are covered by a Large Group Health Plan (LGHP). Medicare secondary payer status for disabled Medicare beneficiaries is based on the "current employment status" of the beneficiaries, their spouses or any other family member. An individual has "current employment status" if the individual is actively working as an employee, the employer, or is associated with the employer in a business relationship.

Prior to August 10, 1993, Medicare was secondary for active individuals under age 65, entitled to Medicare due to disability and covered by a LGHP through a relationship to an employer (i.e. employed or retired beneficiary, spouse or other family member). This provision was based on the "active individual" concept rather than the employment status.

Those disabled beneficiaries who have LGHP coverage as a result of their own or a family member's "current employment status" will continue to have Medicare as the secondary payer. Those disabled beneficiaries who do not have primary coverage with a LGHP because they do not have nor does a family member have "current employment status" will have Medicare as the primary payer.

A LGHP is defined as a plan sponsored or contributed to by an employer or employee organization (union). A LGHP provides medical benefits to employees who are currently working for an employer with 100 or more employees. If more than one employer combines to provide health coverage to their employees and at least one of the employers has 100 or more employees, the requirement is met.

Medicare is primary in the following situations:
Individuals who work for employers of fewer than 100 employees;
Individuals who are covered by a LGHP as the result of past employment (i.e. former retired employee or family member) and whose coverage is not based on "current employment status;"
Individuals who are covered by a health plan that is not provided by a LGHP. An example would be a plan that is purchased privately by an individual rather than through a group plan;
Individuals who have COBRA continuation coverage since it is not based on "current employment status."

c. End Stage Renal Disease (ESRD)
Medicare is secondary payer to group health plans (GHP) for individuals eligible for or entitled to Medicare based on ESRD during a Coordination of Benefits (COB) period. This provision differs from other MSP laws as it applies regardless of the number of employees employed by the employer or their employment status, active or retired. The ESRD provision applies to former as well as current employees. The provision applies where an individual is eligible for Medicare based on ESRD but who has not filed an application for entitlement to Medicare. This provision also applies when an individual is entitled based on ESRD only.
c.1 Coordination of Benefits Period
The Coordination of Benefits period defines the time frame that Group Health Plan benefits pay first, or primary, and Medicare pays second. The COB period begins with the earlier of the first month of entitlement or eligibility for Medicare Part A based on ESRD. Eligibility refers to the first month the individual would have become entitled to Medicare Part A on the basis of ESRD if the individual had filed an application for such benefits.

The length of the coordination of benefits periods has changed several times through the enactment of Medicare laws. If entitlement began before November 5, 1990, Medicare was the second payer for 12 months. If the COB began between November 5, 1990 and March 1, 1996, Medicare was the second payer for 18 months based on the OBRA 1990 law. Effective March 1, 1996, coordination of benefit period is in effect for 30 months. Section 4631(b) of the Balanced Budget Act of 1997, permanently extends the COB for 30 months.
c.2 Dual Entitlement
Medicare entitlement based on ESRD and aged or disability is considered dual entitlement. For example: An individual may be entitled to ESRD and then become entitled based on aged or disability. Or, an individual may be entitled to Medicare based on aged or disability and then develop ESRD.

Anytime an individual is entitled to Medicare for 2 different reasons, they are considered dually entitled. Prior to August 10, 1993, Medicare became primary or first payer on the first day of the month an individual became dually entitled.

The enactment of OBRA 1993 on August 10,1993, changed how dual entitlement affects the coordination of benefits period. Under this law, group health plans must continue to pay primary benefits even if the individual becomes dually entitled during the COB period. If the individual’s entitlement to Medicare was on the basis of aged or disability, and then they became entitled based on ESRD, GHPs were required to pay primary for the COB period. If the GHP was a supplemental plan at the time the individual became entitled based on ESRD, the GHP had to convert to primary payment for the COB period. If the individual did not have GHP coverage, Medicare remained primary in this situation.
c.3 Court Injunction
On May 5, 1995, a lawsuit was filed in the United States District Court, challenging the implementation of one aspect of the OBRA'93 provisions involving beneficiaries who have supplemental group health plan coverage. The court issued a preliminary injunction order on June 6, 1995 that prevents Medicare from applying the rule to services furnished between August 10, 1993 and April 24, 1995 to claims involving GHP retirement coverage pending the court's decision.
c.4 ESRD Entitlement Notes
If an individual has more than one period of Part A eligibility or entitlement based on ESRD, a coordination period is determined for each period of eligibility when the individual has GHP coverage.
Entitlement/Eligibility to Medicare based on ESRD ends 12 months after the month the individual no longer requires maintenance dialysis or 36 months after the month of a successful kidney transplant.
c.5 Effect of COBRA Continuation Coverage on ESRD MSP Provision
COBRA (Consolidated Omnibus Budget Reconciliation Act) requires that certain GHPs offer continuation of plan coverage for 18 to 36 months after the occurrence of certain qualifying events. An example of such an event would be loss of employment or reduction of employment hours. These events could result in loss of GHP coverage unless the individual is given the opportunity to elect continued plan coverage at their own expense. Typically Medicare is primary to COBRA plans with limited exceptions.

COBRA plans may terminate coverage upon entitlement to Medicare with one exception. The exception is that a COBRA plan may not terminate continuation coverage of an individual and his/her qualified dependents if the individual retires on or before the date the employer eliminates regular plan coverage by filing for Chapter 11, Bankruptcy. In this instance, if COBRA coverage overlaps the ESRD MSP coordination period, Medicare is secondary. Medicare will also be secondary if the COBRA plan voluntarily chooses to remain in effect even though they are not obligated to do so under COBRA provisions.

d. Worker's Compensation
Medicare is secondary to Worker's Compensation benefits if the patient is being treated for a work related illness or injury. If the claim is contested, pending the Worker's Compensation Board decision, the physician/supplier may bill Medicare first. A statement should be included on the claim form indicating that the worker's compensation claim is being contested.

Claims for beneficiaries who may have worker's compensation insurance will suspend for manual review to determine whether the services are related to a work illness or injury. If the services are obviously not related to a work illness or injury, the claim will be released for final processing.
Physicians/suppliers should complete item 10a of the CMS 1500 claim form if the services are not provided for diagnosis and treatment of a work related illness or injury.

e. Veterans Administration
Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs. If the veteran elects Medicare coverage, it is not necessary to submit a claim to the Veterans Administration (VA) for a denial before submitting the claim to Medicare. Claims submitted to Medicare will be processed without development, assuming that Medicare coverage and eligibility requirements are met.

Claims cannot be submitted to both programs for the same dates and types of treatment. If a veteran elects Medicare coverage, a claim should not be submitted to the VA for the Medicare deductible or co-insurance.
e.1 Submission of Claims to Medicare or the VA
Submit claims to the VA as follows:
When hospital care was authorized by the VA in advance, or within 72 hours of admission.
When outpatient medical services were authorized by the VA in advance. (NOTE: a VA Fee Basis ID card is not considered by Medicare to be an authorization, and the veteran retains his or her right to elect VA or Medicare coverage.)
When care was not authorized by the VA in advance, the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
Submit claims to Medicare as follows:
When a veteran is eligible for Medicare benefits and hospital care was not authorized by the VA in advance, or within 72 hours of admission. (For services billable on Form 1450, the Medicare provider should enter condition code 26 in field locator 35-39.)
When a veteran is eligible for Medicare benefits, has a VA Fee Basis ID card and elects Medicare coverage over VA.
When a veteran is eligible for Medicare benefits and has no prior authorization from the VA for care—unless the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
When a veteran is eligible for Medicare benefits, and the VA has authorized care for only a part of the hospital treatment period. A denial from the VA is not needed prior to submitting a claim to Medicare.
VA advance authorization for care will be via sharing agreement, contract, or written communication. Telephone authorization may be granted in emergency situations. All telephone authorizations are documented by the VA at the time the authorization is granted.

Any VA authorization for an inpatient is terminated when the veteran is determined by VA to be stable for transfer to a VA facility, or the veteran states that he or she is not willing to be transferred to a VA facility for continued treatment upon stabilization.
Medicare and VA will be performing periodic computer data matches to assure that instances of duplicate payment are identified. When duplicate payments are found, Medicare will pursue recovery of its payment, and will develop information for potential referral to the Internal Revenue Service or the Office of Inspector General.
e.2 Incarcerated Beneficiaries
Medicare is secondary payer for services furnished to individuals in the custody of penal authorities. The state (or other government component which operates the prison) in which the beneficiary resides is responsible for all medical costs incurred. Medicare is primary only if the following conditions are met:
State or local requires those individuals or groups of individuals to repay the cost of the medical care incurred while in custody.
The state or local government entity enforces the requirement to pay by billing the incarcerated individual, whether or not covered by Medicare or any other health insurance.

f. Automobile Accident
Medicare is secondary to all accident related claims. Beneficiaries may not choose which of these claims will be paid by the automobile insurance and which claims will be paid by Medicare. Providers should submit all accident related claims to the automobile insurance before submitting them to Medicare. To avoid late claim filing, claims may be submitted to Medicare even though payment has not been received from the automobile insurer. In addition, conditional payment can be made by Medicare if 1) the automobile insurance will not pay promptly (within 120 days); or 2) due to physical or mental incapacity, the beneficiary fails to meet the claim filing requirements of the automobile insurer. Conditional payments are made on the condition that the beneficiary will reimburse Medicare if payment is later made by the automobile insurer.

If the automobile insurance benefits are exhausted, Medicare requires a statement of exhaustion from the automobile insurer. The itemized statement must include: the dates of service paid and the actual provider who was reimbursed. Note: Claim processing will be denied without this information.

Providers should complete item 10 of the CMS 1500 claim form if the services are related to an automobile accident. If there is information on our files which indicates that a beneficiary has been involved in an automobile accident, the claim will suspend for manual review. If the details referenced on the claim are not sufficient information to process the claim, a questionnaire will be sent to the beneficiary. If a response is not received from the beneficiary within 45 days, the claim will be denied.

g. No-Fault Insurance

Medicare is secondary to all types of insurance that pay for medical expenses for injuries sustained on the property or premises of the insured, regardless of who caused the accident. This type of insurance includes homeowners and commercial plans. It may also be referred to as medical payments coverage, personal injury protection (PIP), or medical expense coverage.

Providers should follow the claims submission guidelines described in the automobile accident section in this chapter. The exhaustion of benefits and conditional payment rules also apply to no-fault insurance.

Medicare does not pay for services paid for or authorized by governmental entities.

h. Liability Insurance
Liability insurance is insurance (including a self-insured plan) that provides payment based upon legally established responsibility for injury, illness or damage to property. It includes, but is not limited to automobile liability and general casualty insurance. It includes payments under State "wrongful death" statues that provide payment for medical damages.

Providers are required to ask Medicare patients, or their representatives, if the services are for treatment of an injury or illness that resulted from an automobile accident or other incident for which the patient holds another party responsible. The provider should obtain the name, address, and policy number of any automobile or non-automobile liability insurance, no fault insurance, or any other party that may be responsible for payment of medical expenses that result from an accident or injury.

Where a provider has reason to believe that he/she provided services to a Medicare beneficiary for whom payment under liability insurance may be available, the provider may:
Within the 120 day promptly period, the provider must bill only the liability insurer unless there is evidence that the liability insurer will not pay within the 120 day promptly period. If the provider has such evidence, he/she may bill Medicare for conditional payment, provided that documentation is supplied to support the fact that payment will not be made promptly; or
After the 120 day promptly period has ended, the provider may, but is not required to, bill Medicare for conditional payment if the liability insurance claim is not finally resolved. If the provider chooses to bill Medicare, he/she must withdraw claims against the liability insurer or a claim against the beneficiary's settlement. If the provider chooses to continue with a claim against the liability settlement, the provider may not bill Medicare.
h.1 If a provider participates in the Medicare program
Provider bills Medicare - The provider must accept the Medicare approved amount as payment in full and may charge beneficiaries only for deductible and coinsurance; or Provider pursues liability insurance - The provider may charge the beneficiaries actual charges up to the amount of the proceeds of the liability settlement, but he/she may not collect payment from the beneficiary until after the proceeds of the liability insurance are available to the beneficiary.
h.2 If a provider does not participate in the Medicare program:
Provider bills Medicare accepting assignment - The provider may accept the Medicare approved amount as payment in full and may charge the beneficiaries only for deductible and coinsurance; or
Provider bills Medicare not accepting assignment - The provider may charge beneficiaries no more than the limiting charge and may collect without regard to whether the liability insurance is available to the beneficiary.
For services for which there is no Medicare coverage available regardless of whom furnishes them, the provider may charge and collect actual charges from beneficiaries without regard to whether the proceeds of liability insurance are available to the beneficiary.

i. Black Lung Benefits
Medicare is secondary for beneficiaries who have medical benefits under the Federal Black Lung Program. Medicare is secondary only for services provided for the treatment of lung conditions caused by mining. Claims for beneficiaries entitled to benefits under the Federal Black Lung Program may suspend for manual review. If the diagnosis or services reported on the claim are not related to the black lung condition, Medicare is primary and the claim will be released for final processing.

For some beneficiaries entitled to the Federal Black Lung Program, the coal mine operator is responsible for medical benefits. In these cases, providers should submit the claims to the coal mine operator or its Workers' Compensation plan for processing.

j. Primary Insolvency
In accordance with the Centers for Medicare & Medicaid Services (CMS) requirements, when a primary payer becomes insolvent, Medicare payments will not be made unless the claim is accompanied by an Explanation of Benefits from the receiver (substitute primary payer decided on by the courts) and the court order of payment.

Physicians and suppliers who accept assignment may not collect or seek payment from the beneficiary or their estate for any Medicare covered service(s) during the primary insurer's insolvency process. Providers should file their claims with the primary insurer or the receiver if they have not already done so.

The receiver will determine the full primary payment to be made. Once you have been paid by the receiver, you may bill Medicare for secondary payments, if appropriate. You will have six (6) months from the date of the receiver's Explanation of Benefits to file a claim for secondary payments with Medicare. If the claim is received after the six month filing limit, it will be processed as untimely.

In order for Medicare to process these claims for secondary payment, please provide the following:
A hard copy of the claim;
An Explanation of Benefits from the receiver;
A copy of the court order that addresses this issue.

k. Employer Plan HMO Coverage
The Centers for Medicare & Medicaid Services has clarified that providers are responsible for submitting claims to Medicare for secondary payment consideration when the primary insurer is a Health Maintenance Organization (HMO). Medicare may consider secondary payment for all or part of an employer-sponsored HMO's copayment.

An HMO pays providers a monthly capitation fee to care for its members. Because of this reimbursement, there are no billed charges for the rendered services. Medicare will consider the Medicare fee schedule amount as the billed charge. This amount will also be considered the primary insurer's allowed amount in calculating Medicare liability. The Medicare claim form submitted for the HMO copayment can be completed with standard information:
Item 24F (charges) – Enter the charge for each listed service
Item 28 (total charge) – Enter total charges for the services (i.e., total of all charges in item 24f)
Since providers collect HMO copayments at the time of service, a copayment receipt signed by the beneficiary must be submitted with the claim. The receipt will be accepted in lieu of the primary benefits statement or explanation of benefits (EOB) required in all other Medicare secondary payer situations. The receipt must clearly indicate "HMO copayment." To assist you with this requirement, you may copy the form shown below and use it for this purpose.
When an acceptable co-payment receipt is not submitted with a claim, payment for these services may be delayed or could result in a denial of the claims. HMO co-payment receipts submitted with Medicare Secondary Payer claims should meet certain requirements.
The original co-payment receipt, signed by the beneficiary on the date they were seen should be attached to the claim form.
should be one receipt for each date of service submitted on the claim form.
If the patient did not pay the co-pay at the time of the service, a co-pay receipt should not have been submitted with the claim. A receipt should only be issued to the patient if the patient paid the co-pay at the time of their service.
Medicare will send any reimbursement for non-assigned claims submitted for HMO copayment to the beneficiary. For assigned claims submitted for HMO copayment, Medicare's payment will be sent to the provider who in turn must reimburse the beneficiary.

k.1 Services Obtained Outside the HMO Plan
Generally, Medicare will not pay for services obtained from a source outside the HMO plan. If a beneficiary wants or needs to go to a provider outside the plan, an authorization must be obtained from the HMO plan. If authorization is not obtained, the HMO will not make payment. If the beneficiary has not been notified in writing of this rule and the HMO will not make payment, Medicare will process the claim for payment. Once the beneficiary has been notified, Medicare payment will not be made for future services obtained outside the plan.

Sunday, June 7, 2015

When Medicare Pays First, Second or Even Third

When Medicare began in the 1960s, it was the primary payer for all services except those covered by workers compensation. Then in 1980, Congress enacted provisions to shift costs from the Medicare program to private insurers, when possible. This legislation stopped Medicare from making payment if the payment has already been made, or would be expected to be made, by Group Health Plans (GHP) and Workers Compensation (WC) Plans.

Medicare Pays First When:
You have retiree insurance (from either you or your spouse’s former employment)
You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has less than 20 employees
You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has less than 100 employees
You’re also receiving Medicaid benefits
Note: If you have group health care plan coverage that is primary to Medicare (pays first), it will continue to do so until it pays up to the limits of its coverage. Then Medicare becomes primary.

Medicare Pays Second When:
You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has 20 or more employees
You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has 100 or more employees
You have End-Stage Renal Disease (ESRD) and you are in the first 30 months your Medicare eligibility. Then Medicare pays first after that.
You’re covered by no-fault or liability insurance for an services related to an accident

Insurance that pays after Medicare is referred to as supplemental insurance. Your retiree coverage may act as supplemental insurance or you may purchase a Medigap policy from a private insurance company.
Medicare works supplemental insurance companies through a process called ‘crossover.’ Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

If your supplemental insurance does not participate in crossover with Medicare, you will be responsible for ensuring your insurance receives information about claims Medicare has processed. Many providers will file claims to your supplemental insurance after Medicare has processed your claim. If you provider will not file to your supplemental insurance, contact the plan to verify what information they will need to process a claim. Many supplemental insurance plans will ask you to send a copy of your Medicare Summary Notice (MSN). If you need an MSN, you may request one from our Customer Service unit.

Wednesday, May 27, 2015

Medicare non covered items and services - part 1


The following four categories of items and services that are not covered under the Medicare Program are discussed in this publication:
1)Services and supplies that are not medically reasonable and necessary;
2)Non-covered items and services;
3)Services and supplies that have been denied as bundled or included in the basic allowance of
another service; and
4) Items and services reimbursable by other organizations or furnished without charge.
Where applicable, exceptions (items and services that may be covered) are also included in this discussion.

1)    Services and Supplies That Are Not MedicallyReasonable and Necessary

Services and supplies that are not medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary’s condition will not be covered. Some examples include:
• Services furnished in a hospital that, based on the beneficiary’s condition, could have been
furnished in a lower-cost setting (for example, the beneficiary’s home or a nursing home);
• Hospital services that exceed Medicare length of stay limitations;

• Evaluation and management services that exceed those considered medically reasonable and
• Therapy or diagnostic procedures that exceed Medicare usage limits;
• Screening tests, examinations, and therapies for which the beneficiary has no symptoms or documented conditions,with the exception of certain screening tests, examinations, and therapies as described under Exceptions;
• Services not warranted based on the diagnosis of the beneficiary (for example, acupuncture and
transcendental meditation); and
• Items and services administered to a beneficiary for the purpose of causing or assisting in causing death (assisted suicide).
In general, Medicare-covered services are those services considered medically reasonable and necessary to the overall diagnosis or treatment of the beneficiary’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:
• Proper and needed for the diagnosis or treatment of the beneficiary’s medical condition;
• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition; and
• Not mainly for the convenience of the beneficiary, provider, or supplier.

Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For every service billed, you must indicate the specific sign, symptom, or beneficiary complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment
for services without beneficiary symptoms or complaints or specific documentation.


• Annual Wellness Visit;
• Initial Preventive Physical Examination (also known as the “Welcome to Medicare Preventive
• Colorectal cancer screening;
• Screening mammography;
• Clinical breast examinations;
• Screening Pap tests;
• Screening pelvic examinations;
• Prostate cancer screening;
• Cardiovascular disease screenings;
• Diabetes screening tests;
• Glaucoma screening;
• Human Immunodeficiency Virus (HIV) screening;
• Bone mass measurements;
• Medical nutrition therapy (for certain beneficiaries diagnosed with diabetes, renal disease, or who
have received a kidney transplant within the last 3 years);
• Diabetes Self-Management Training (for beneficiaries diagnosed with diabetes);
• Vaccines;
• Ultrasound screening for abdominal aortic aneurysm;
• Intensive behavioral therapy for cardiovascular disease;
• Intensive behavioral therapy for obesity;
• Counseling to prevent tobacco use for asymptomatic beneficiaries;
• Screening for depression;
• Screening and behavioral counseling interventions in primary care to reduce alcohol misuse; and
• Screening for sexually transmitted infections (STI) and high intensity behavioral counseling
to prevent STIs. Items and services  administered for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, may be covered provided they are not furnished for the specific purpose of causing death.

Monday, May 18, 2015

Medicare Preventive Visit, the Annual Wellness Visit and Routine Physical Exams: Three Different Services, Only Two Are Covered by Medicare

When you go to the doctor for a once-a year examination, it’s important that both you and your doctor know what kind of exam you are there for.

Medicare pays for a one-time ‘Welcome to Medicare’ preventive visit within the first 12 months you have Part B coverage. During this visit (also called the ‘Initial Preventive Physical Exam’), your doctor will obtain information on your medical and social history related to your health. ‘Social history’ can mean any history of alcohol, tobacco or other drug use, and your diet and physical activities. Your doctor will measure your blood pressure, weight, height, body mass index, and screen your vision. Your doctor will also give you guidance or advice on preventive services you may wish to consider including certain screenings, shots, and referrals for other care, if needed. You should receive a brief written plan or checklist for the Medicare-covered screenings that you are eligible for.

For this visit, bring your medical records (if your doctor doesn’t have them), including immunization records. Also bring a record of the prescription drugs you are taking, as well as any over-the-counter medications and vitamins you use. If you are new to the doctor conducting this exam, he or she is going to want to know why you were prescribed these medications or take the over-the-counter medicines and vitamins.

When we say ‘doctor’ for the ‘Welcome to Medicare’ visit, we mean a physician (doctor of medicine or osteopathy) or a qualified non-physician (such as a physician assistant, nurse practitioner, or certified clinical nurse specialist).

While you are not required to have this examination, you pay nothing for this visit if your doctor accepts assignment, and the Part B deductible doesn’t apply. This is one preventive service that’s too good to pass up! When you make your appointment, let your doctor’s office know that you would like to schedule your “Welcome to Medicare” preventive visit.

Twelve months after the ‘Welcome to Medicare’ visit, you are eligible for an ‘Annual Wellness Visit’. Or, if you did not have the ‘Welcome to Medicare’ service, you can have the ‘Annual Wellness Visit’ once you have had Part B Medicare coverage for longer than 12 months. 

The Annual Wellness Visit can be performed by a ‘health professional’, including a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a health educator, registered dietician, nutrition professional, or other licensed practitioner. This would include a team of medical professionals working under the direct supervision of a physician.
During your first wellness visit, your provider will develop or update a personalized prevention plan based on your current health and risk factors. They will inquire or ask you to update your medical and family history. They will also check your blood pressure, measure your height and weight, and conduct other routine measurements.

They will review any potential risk factors for depression, your ability to function, as well as other mental attributes.
Other components of this visit: developing a written schedule or checklist for the next five to 10 years, discussing any risk factors and giving health advice or referrals for health education.

After your first Annual Wellness Visit, you are eligible for future wellness visits once every 12 months. You don’t need to wait until the exact date each year to have the exam; you only have to wait until the same month every year.
Like the ‘Welcome to Medicare’ visit, you pay nothing for the ‘Annual Wellness Visit’ if your doctor accepts assignment, and the Part B deductible doesn’t apply. When you make your appointment, let your doctor’s office know that you would like to schedule your “Annual Wellness” visit.

During both the ‘Welcome to Medicare’ visit and the “Annual Wellness” visit, your doctor may order tests or make referrals for other services based on your general health and medical history. Payments for other services you receive from your doctor or based on a referral from your doctor, including laboratory tests and EKGs, are not included in the payment for visit and will be billed separately. You may have to pay coinsurance, and the Part B deductible may apply, to those services.

While both the ‘Welcome to Medicare’ preventive visit and the ‘Annual Wellness Visit’ are covered by Medicare, routine physical examinations or yearly check-ups are not covered by Medicare. The Medicare-covered preventive visits include specific components that your doctor must perform to be able to bill for the covered service. That is why it is important that your doctor and your doctor’s staff know what type of visit you are scheduled for. If your doctor is not aware that you are there for one of the Medicare-covered preventive visits, he or she may conduct a routine physical exam instead.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.

Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)

Medicare Physician Fee Schedule Payment Rates Formula

The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +

Medicare fee schedule download