Physical Therapy on a Plan N

[selfgen]

I had always understood that the “up to $20” co-pay only applies to a specific range of Medicare codes for consultation with a doctor or provider. Bottom line, I didn’t think PT sessions would trigger this copay. Another agent is telling me it would. Does anyone here know?

 

[vic120]

supposed to not be a copay

However some places do charge PT as copay

When that started around 2015 I used to fight it and won
At that time it was rare

By 2018 or so it was happing more often and places were fighting it harder

So by 2019 I decided to tell people they may or may not charge you as doc for PT because its too time consuming to deal with

The truth is its in the coding PT is not supposed to be copay legally speaking but they get away with it

 

[LostDollar]

Caveat, not an agent.

It seems to me like this has been discussed here before and the issue is in coding.

I'm thinking that someone posted a series of 4-5 office visit billing codes that legitimately had the co-pays under plan N, and that they were all for physicians. It seems like the discussion then went on say that codes for physical therapy should not incur the co-pays.

So the key, as long as the therapy has been prescribed by a physician, is probably to look at the Medicare Summary Notice and see what the billing code is. If it is a physician office visit code, then the PT company needs to resubmit the bill under a code appropriate to them.

Depends on how much trouble the Medicare Beneficiary wants to go to get out of the co-pay.

 

[ICACharleston]

MA plans treat physical therapists as specialists -same copay with years less schooling.

 

[vic120]

Caveat, not an agent.

It seems to me like this has been discussed here before and the issue is in coding.

I'm thinking that someone posted a series of 4-5 office visit billing codes that legitimately had the co-pays under plan N, and that they were all for physicians. It seems like the discussion then went on say that codes for physical therapy should not incur the co-pays.

So the key, as long as the therapy has been prescribed by a physician, is probably to look at the Medicare Summary Notice and see what the billing code is. If it is a physician office visit code, then the PT company needs to resubmit the bill under a code appropriate to them.

Depends on how much trouble the Medicare Beneficiary wants to go to get out of the co-pay.

right but after spending much time and arguing it Coupled with the fact that it happens much more frequently and discovering these offices will fight to code they way they want

Its not worth the time and effort to get them all to rebill

better the let the client know they may be billed for it

 

[kgmom219]

Plan N does not require copays for PT.

On the other hand, the damn card says $20 copay and the front desk people cannot be expected to get the nuances of 100’s of plans.

At the time of sale for Plan N, bring up this issue, because it’s 100% going to happen. (My slide on this is titled “I don’t like calls that begin with you never told me…”

From a practical perspective, have the client pay the first $20 but ask them to contact the Med Supp carrier to confirm they owe the $20 copay. Most of the time, my clients get a refund before they leave the 1st session.

 

[wehotex]

I had always understood that the “up to $20” co-pay only applies to a specific range of Medicare codes for consultation with a doctor or provider. Bottom line, I didn’t think PT sessions would trigger this copay. Another agent is telling me it would. Does anyone here know?

About 10 years ago, I called my Dad’s PT place if they would charge the LESSER of my Dad’s HMO copay ($25-30 at the time, I think) OR LESSER if the Original Medicare was lesser? Their reply was that they would charge the copay of the MAPD that dad belonged to.
At that time, thru told me that OM FFS rate was $17. It has gotta be AT LEAST $20 by now.

Now that I’ve read the other comments, it might be something unique to Plan N?

 

[LostDollar]

https://insurance-forums.com/community/threads/plan-n-no-20-copay-on-physical-therapy.24466/page-3

That thread has a series of posts from 2015 that I think provide useful background information to the issue.

 

[Travis Price]

PT can have a copay. The coding is what matters, but specifically it has to be an examination and treatment, and it has to be by a doctor.

Personally, I still don't sell Plan N in enough quantities to fight it. The gap between G and N isn't wide enough, imo, to recommend it for the extra headache.

Will there be a time where it becomes the standard? Yes. For me, not yet.

Your patient should NEVER pay in advance of the MSN for Medicare services. It's a lot easier to pay a bill after the claims process and appeal vs trying to get your money back.

 

[kgmom219]

PT can have a copay. The coding is what matters, but specifically it has to be an examination and treatment, and it has to be by a doctor.

Personally, I still don't sell Plan N in enough quantities to fight it. The gap between G and N isn't wide enough, imo, to recommend it for the extra headache.

Will there be a time where it becomes the standard? Yes. For me, not yet.

Your patient should NEVER pay in advance of the MSN for Medicare services. It's a lot easier to pay a bill after the claims process and appeal vs trying to get your money back.

I despise Plan N. I will only use it cases where I don't want an SSA only person going on MAPD, because they damn sure don't have the $1500 to get their hip replaced.

"Here's my answer on Plan N. My grandmother at age 90 had the money to pay the $20 copays. What she did NOT have is the physical or cognitive ability to do so" #whatsnext