I was speaking recently at the SOMSA meeting in St. Pete’s…it was so nice to be around people again and see so many friends and colleagues that I have missed this past year! If you were not able to attend I strongly encourage you to plan on being there next year for the annual meeting. It’s a must do!
One of the hot topics this year was Medicare…whether you are a participating provider or an opt out provider there are still some guidelines and rules you need to follow. With the influx of Medicare Advantage Plans on the market and the growing number of baby boomers each year, Medicare and Medicare Advantage plans are impacting our practices more
Medicare Advantage Plans replace traditional Medicare. Patients are allowed to shop for plans in their local market that may have more benefits and flexibility than traditional Medicare plans. Many of these plans include add-ons such as dental, vision, etc. This pdf has a lot of good information comparing the options.
When reviewing the cards the patient gives you at the time of their appointment, the traditional Medicare card (red, white and blue) should have listed on it Part A and Part B benefits. If that is the case (and it's an up to date card) then the patient has traditional Medicare. If the patient presents to you a card from UHC, BCBS, Humana,
etc. that has the word Medicare listed on it, or has Medicare benefits apply, then the patient has a Medicare Advantage Plan and you should not be billing traditional Medicare for provider services.
Under these plans what guidelines does a provider have based on official Medicare status?
Let’s start with Participating Providers. Providers are required to do the following:
- Submit claims for all services that are potentially covered under Medicare
- Non covered services must be submitted to Medicare if the patient requests.
- Complete an ABN form for services you are not sure will be covered by Medicare based on medical necessity. This ABN form (Advanced Beneficiary Notification) must be completed prior to the procedure. This document must be patient and procedure specific; it cannot be signed for every patient that comes in the door. Keep these forms on file and make sure you attach
the appropriate modifier to the claim to let the carrier know you did complete the ABN.
- Allowed to bill Medicare Advantage plans for services.
- Make sure you check the specific policies. Some of these are HMO plans and will require for patients to be seen by an in network provider.
Here are few key modifiers that can be used for CMS claims.
GA ABN completed and on file
GY Non covered service, claim sent at the request of the beneficiary
GJ Opt out provider, emergency services rendered.
As an opt out provider the following applies:
Private Contract must be signed for all Medicare beneficiaries. This must be signed prior to receiving treatment (unless an emergency situation at the hospital). There is specific language that is preferred by Medicare to be used in this contract. Here is a link to a sample document that you can use to create one for your practice. Basically this contract states that you will not and cannot bill Medicare for any services and the patient is agreeing to the same (i.e. no claims will go to Medicare for the services you render).
As part of your opt out status the provider is agreeing to not accept payment from any Medicare funds. Keep in mind that Medicare Advantage Plans (Part C of Medicare) are technically Medicare funds. Therefore, if you have opted out of Medicare, you have also opted out of Medicare Advantage plans. Many plans have a dental rider embedded
in the policy. If that is the case and you have opted out, neither you or your patient will be able to submit claims to Medicare Advantage Plans.
As an opt out provider you do have the option to opt out but maintain the ability to order and refer services. This is an important component to consider as an add on to the Opt Out Status. If you do not ask for this option then if you order or refer services for a Medicare beneficiary (i.e. lab work at the hospital, pathology, etc) then the other
entity (i.e. lab) will not be able to get paid either. So make sure you are following all of the rules that come along with an opt out!
These plans seem to be getting more and more confusing by the day and certainly the number of patients we are seeing with these plans is increasing as well. Whatever decision you make regarding your Medicare status, do your due diligence to be sure you are fully aware of what you are signing up for or not signing up for and how this decision can impact
Until next time…Keep Calm and Code On!