Part B Excess Charges

[yorkriver1]

I am trying to imagine the original charges for that 6 figure amount that Medicare and MedSupp paid. Medicare seems to pay about 1/3 or less of original charges. Never seen 6 figure outpatient procedure, any specific examples?

Lately the EOB's I see go like this: billed--$3,119 for test, Medicare approved
$726, Medicare paid $471, $108 applied to deductible (remaining, $39 already incurred), MedSupp paid $147, rounding #'s, I am reading from actual EOB.
Next page: physician's fee:
$1,141, Medicare approved: $259, Medicare paid: $207, MedSupp: $52.

 

[MatthewC]

While only 4% of doctors are non-participating and may have excess Part B charges, the percentage of non-participating hospitals may be more. I believe excess part B charges are more common from hospital outpatient services that from individual doctors.

In addition, if your client wants the freedom of going to any specialty hospital without having to worry about excess charges, then Plan N would not be their best choice. Check out Mayo clinic for example: (search may clinic medicare billing)

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If I could post links, I would post this one from Mayo clinc on the subject:

just copy and paste as is:
mayoclinic.org/patient-visitor-guide/minnesota/billing-insurance/faq/medicare-faq

If your client wants original medicare for the freedom of going to any specialty hospital or specialist in the country, excess Part B charges is an issue and should be included in their decision making process.

 

[GreenSky]

While only 4% of doctors are non-participating and may have excess Part B charges, the percentage of non-participating hospitals may be more. I believe excess part B charges are more common from hospital outpatient services that from individual doctors.

In addition, if your client wants the freedom of going to any specialty hospital without having to worry about excess charges, then Plan N would not be their best choice. Check out Mayo clinic for example: (search may clinic medicare billing)

----------

If I could post links, I would post this one from Mayo clinc on the subject:

just copy and paste as is:
mayoclinic.org/patient-visitor-guide/minnesota/billing-insurance/faq/medicare-faq

If your client wants original medicare for the freedom of going to any specialty hospital or specialist in the country, excess Part B charges is an issue and should be included in their decision making process.

Are you suggesting that Part A is subject to excess charges?

Rick

 

[MatthewC]

"Are you suggesting that Part A is subject to excess charges?"

No.

Outpatient services from a hospital are Part B charges. In-patient services are part A.

From personal experience -- I have had 8 surgeries in my life. Only one (way back in 1977) was in-patient. All other surgeries were outpatient services. Hospitals are steering medical services more and more toward outpatient services, and that means more Part B for those on Medicare.

My mother just had surgery for cancer. In her case the surgery was inpatient, but all the other cancer related services and follow up (radiation, chemo etc.) are outpatient.

Think of it this way; a hospital only has a limited number of beds. They can't grow that portion of their business without adding buildings. However, they can convert services to outpatient and the sky is the limit.

Full disclosure: My wife has a 2 year degree in Medical billing and is Medicare billing certified. She works at a local hospital --billing dept. It is her day-to-day experience on which I rely for much of my information on this subject.

 

[sman]

While only 4% of doctors are non-participating and may have excess Part B charges, the percentage of non-participating hospitals may be more. I believe excess part B charges are more common from hospital outpatient services that from individual doctors.

You believe? So do you have any empirical evidence to back up your belief? I think you'd be hard pressed to find a hospital that doesn't accept assignment. It's the exception and not the rule. With that said, in an outpatient surgery setting it's quite possible the anesthesiologist could be non-par.

Let's be honest, if this were a big deal we'd be hearing horror stories by now of those who are on Plan N.

 

[somarco]

those who are on Plan N.

Also plan A, B, C, D, K, L or M.

If a hospital accepts govt funds they are required to accept assignment of Medicare benefits. I assume this extends to their outpatient services which includes the ER as well as any off-site facilities.

My PCP practice is owned by a hospital and we are billed by that hospital. The forms we sign say we are assigning benefits to the hospital and will allow them to bill on our behalf.

MatthewC you are simply stating what most of us already know with regard to outpatient services. If you are also arguing that these hospital outpt settings do not accept assignment then clarify your position.

And your other statement that the number of non-par hospitals are greater than 4% would be considered if you have a citation.

The Mayo situation is unusual and only occurs in a few of the clinics.

 

[bluediamond]

Mayo clinic in Jacksonville, Fl does not accept Medicare assignment for Part B charges:

Your Medicare coverage and claims - Florida Patient and Visitor Guide - Mayo Clinic

 

[MatthewC]

A Reply to Sman and Somarco

Wow –

This is very entertaining.
Please read carefully before responding.

Re: "You believe? So do you have any empirical evidence to back up your belief?"

Yes, I believe that to be the case. I stated such. My belief is based on my experience and my search of top specialty hospitals in the country and their Medicare billing. It takes some leg work, but if you are selling Medigap plans and suggest the client can go anywhere for coverage, you should know if that means they will face Part B excess charges. I can say from the experience of doing that leg work that it appears to me that more than 4% of those hospitals are non-participating. That is my opinion.

I often use examples like –" If you have cancer, stroke etc. you are sick and vulnerable and you want to know you can get the best care in the country, not just the local doctor. With Plan G you can go to virtually any specialty hospital in the country and it will be covered by your Medigap / Medicare plan."

Re: "I think you'd be hard pressed to find a hospital that doesn't accept assignment. "

Perhaps I wasn't as clear as I should have been in my statement. The data we have all seen from the Kaiser foundation refers to doctors, not hospitals. They are different entities, different numbers and different percentages. To assume that just because only 4% of doctors are non-participating, 4% of hospitals are the same is just that, an assumption. I believe very few hospitals are non-participating, but I also believe that patients who experience surprise excess Part B charges do so more from a hospital than from their doctor. That is what was meant from my comment, albeit stated in fewer words.

My statement: "While only 4% of doctors are non-participating and may have excess Part B charges, the percentage of non-participating hospitals may be more. I believe excess part B charges are more common from hospital outpatient services that from individual doctors." Emphasis on those words that appear to have been misunderstood.

"Let's be honest, if this were a big deal we'd be hearing horror stories by now of those who are on Plan N."

Not necessarily. Do the math, or look up those that have done the math for you. United American, for example, has a great presentation showing a hypothetical $93,952 medical bill. In this example the person with a Plan F pays $0, with Plan G pays $147, with Plan N pays $4,592 because their insurance did not cover Part B excess charges.

Is that a horror story? Probably not, unless the client is living paycheck to paycheck. But if I sold them a plan and just Poo Poo'd the potential for excess charges as something that won't happen I would consider myself negligent, and they probably would too. If an agent lead me to believe that excess part B charges were not an issue to be concerened with, and I ended up with a surprise bill...that agent would be on my sh!t list and depended on how that agent presented the issue to me , may get sued.

Re: "My PCP practice is owned by a hospital and we are billed by that hospital. The forms we sign say we are assigning benefits to the hospital and will allow them to bill on our behalf."

I assume "PCP" is not referring to the drug.

That's one hospital. If I were to make the same leap you made, I would start arguing that you are stating all hospitals are the same.

Re: "If you are also arguing that these hospital outpt <sic> settings do not accept assignment then clarify your position."

Re: "And your other statement that the number of non-par hospitals are greater than 4% would be considered if you have a citation."

I did not make such a statement, I clearly used the phrase "may be". Again, data specific to number or percentage of doctors cannot be translated to hospitals. A number of specialty and nationally high ranked hospitals are non-participating.

Re: "The Mayo situation is unusual and only occurs in a few of the clinics."

You are absolutely and totally incorrect. I would ask you to reference, but since I already have such opposing data I don't need you to. Please look up Mayo Clinic in the various states. Once you are on their specific site, search for Medicare Billing. I have not yet found one that does not state it is non-participating. In fact, some will even state "Like all Mayo Clinic's we are nonparticipating with Medicare." leading me to conclude that "ALL" is an appropriate referrence.

Now – how many of you go the extra step and educate your clients on the one way their participating or non-participating doctor or hospital can charge them for services not covered by Medicare?? It is the one way that many patients get huge surprise bills they must pay.

Hint: It's a form often slipped in with a stack of other forms and HIPA information while they are already ill and under "stress". They have three choices on this form – two will mean they are billed, one denies the service.
If they deny service and the service is medically necessary, the hospital or doctor has to do it anyway and cannot bill the patient.

Hospitals / doctors must list the price they charge for whatever procedure referrenced on the form. They do not need to charge Medicare rates, even if it is a procedure regulary covered by Medicare. (ie if Medicare pays for one mamagram per year and this is a second mamagram within 12 months --that is a procedure regularly payed by medicare but would not be covered in this case) So, the forwarned patient can negotiate the rate down to the medicare rate (often 15%-18% of the original charge on this form) if they are forwarned. Otherwise...Ouch!

Anyone?

 

[GreenSky]

Wow -

This is entertaining.

I just love the doom and gloom insurance agent. Aside from Mayo, name ONE hospital that doesn't accept assignment. (Yes, you must show your work).

Rick

 

[MatthewC]

No, I don't need to show my work.

I have already wasted half my afternoon clarifying misread assumptions.

I am not doom and gloom either.