Uncomfortable Issue- Need an Answer

insuranceconceptscindy

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My client, a 65+ woman, went to the gynecologist for a routine annual with all of the regular testing. She has Medicare and Plan F.

I got a fax from her with 2 bills totaling more than $400. Luckily, she included the Medicare EOB. Medicare's denial code was: "routine examinations and related services are not covered." Which is BS. This is considered preventative care.

According to medicare.gov, all of the tests she had are covered services. (These tests included STD screening.)

Thoughts on which direction to go? The CPT codes do not show me that it would be denied, according to the internet.

I really don't want to have a discussion about STD's with this woman. . .
 
My client, a 65+ woman, went to the gynecologist for a routine annual with all of the regular testing. She has Medicare and Plan F.

I got a fax from her with 2 bills totaling more than $400. Luckily, she included the Medicare EOB. Medicare's denial code was: "routine examinations and related services are not covered." Which is BS. This is considered preventative care.

According to medicare.gov, all of the tests she had are covered services. (These tests included STD screening.)

Thoughts on which direction to go? The CPT codes do not show me that it would be denied, according to the internet.

I really don't want to have a discussion about STD's with this woman. . .

Call Doctor's office and request they refile.. Send the client an email or a note telling her you have requested this of the Dr,s office.
 
I would start by asking when was her last exam, because, I had a customer with the same issue and the answer was: she didn't wait an entire calender year for her next exam, it was within a few weeks of being a year so it was denied.
Hope this helps.
 
I would start by asking when was her last exam, because, I had a customer with the same issue and the answer was: she didn't wait an entire calender year for her next exam, it was within a few weeks of being a year so it was denied. Hope this helps.
I was thinking the same thing. Also, some of these preventive exams are every two years unless a person is in a high risk category.
 
If she got a bill and this is service regularly covered by Medicare then she must (or was supposed to) have signed an ABN (Advanced Beneficiary Notice) giving the Dr the right to bill her. Find out which option she picked on the ABN form. If she signed the form and gave tem permission to bill her, then she is responsible. If she did not sign an ABN form then she isn't supposed to get a bill and you have a case that she is not required to pay. Some of the routine exams are only covered once every 24 months. If she has a second exam within 24 months it is not covered by medicare, but an ABN form must be signed and completed properly for the benficiary to be billed and legally obligated to pay.

I can't post links yet, but look up ABN on CMS or Medicare.gov Look up Advanced Beneficiary Notice of Noncoverage (ABN) booklet, page 13, first paragraph. This booklet is directed toward Healthcare providers. The "You" they refer to is the healthcare provider.

"WHAT IF I FAIL TO ISSUE A MANDATORY ABN OR ISSUE A
DEFECTIVE ABN?

You will likely be financially liable for items or services if you knew, or should have known, Medicare would not pay for a usually covered item or service and you fail to issue an ABN or issue a defective ABN. In these cases, you cannot collect funds from the beneficiary, and Medicare requires you to make prompt refunds if you previously collected payment."

A copy of the ABN form is on page 11.

Also Medicare.gov on ABN :

"Advance Beneficiary Notice of Noncoverage

If you have Original Medicare and your doctor, other health care provider, or supplier thinks Medicare probably (or certainly) won't pay for items or services, they may give you a written notice called an "Advance Beneficiary Notice of Noncoverage" (ABN). However, an ABN isn't required for items or services that Medicare never covers.

The ABN lists the items or services that Medicare isn't expected to pay for, an estimate of the costs for the items and services, and the reasons why Medicare may not pay. The ABN gives you information to make an informed choice about whether or not to get items or services, understanding that you may have to accept responsibility for payment."
 
I would start by asking when was her last exam, because, I had a customer with the same issue and the answer was: she didn't wait an entire calender year for her next exam, it was within a few weeks of being a year so it was denied.
Hope this helps.


Yep that is it, when I scheduled my annual physical this year I was told by Doctor's office can't have until it's been one year and a day for Medicare or MAPD to pay. Guess I should have known that, but didn't.
 
If she got a bill and this is service regularly covered by Medicare then she must (or was supposed to) have signed an ABN (Advanced Beneficiary Notice) giving the Dr the right to bill her.
You may have just left out a key word. ABN is for services not typically covered by Medicare. ABN is not required for services regularly covered by Medicare.
 
You may have just left out a key word. ABN is for services not typically covered by Medicare. ABN is not required for services regularly covered by Medicare.

That is incorrect. The ABN is required to bill a beneficiary for services Medicare may typically cover, but not cover in this case.

An ABN is not required for services that Medicare never covers (i.e. dental), but it is required to bill a beneficiary for services Medicare may normally cover. The OP's example is perfect for this. If the service is one that Medicare covers every 12 or 24 months and the DR. knows or is not certain enough time has passed for the service to be covered, then an ABN is required or the beneficiary is not obligated to pay the bill.

The objective of an ABN is two fold; one is that it prevents a healthcare provider from having proceedures done more often than is necessary, and two it forewarns the beneficiary of potential charges so that they can make a decision fully aware that they may be liable for the cost.

Please see the ABN booklet: http://www.cms.gov/Outreach-and-Edu...NProducts/downloads/abn_booklet_icn006266.pdf

from page 1:

"The Centers for Medicare & Medicaid Services (CMS)
implemented the Advance Beneficiary Notice of Noncoverage
(ABN), Form CMS-R-131, to inform Part B and certain
Part A Original Medicare beneficiaries when Medicare may
deny payment for an item or service. This booklet provides
information to help health care professionals understand the
Medicare requirements for when and how to issue an ABN."

"An ABN, Form CMS-R-131, is a standardized notice you or
your designee must issue to a Medicare beneficiary before
providing certain Medicare Part B (outpatient) or Part A
(limited to hospice, home health agencies [HHAs], and
Religious Nonmedical Healthcare Institutions only) items or
services. You must issue the ABN when:
■ You believe Medicare may not pay for an item or service;
Medicare usually covers the item or service; and
Medicare may not consider the item or service
medically reasonable and necessary for this patient in
this particular instance."



"ABNs allow
beneficiaries to make informed decisions about whether
to get services and accept financial responsibility for those
services if Medicare does not pay. The ABN serves as
proof the beneficiary knew prior to getting the service that
Medicare might not pay. If you (healthcare provider) do not issue a valid ABN to the beneficiary when Medicare requires it, you cannot bill
the beneficiary for the service and you may be financially
liable if Medicare doesn't pay."
 
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That is incorrect. An ABN is not required for services that Medicare never covers (i.e. dental), but it is required to bill a beneficiary for services Medicare may normally cover. The OP's example is perfect for this. If the service is one that Medicare covers every 12 or 24 months and the DR. knows or is not certain enough time has passed for the service to be covered, then an ABN is required or the beneficiary is not obligated to pay the bill. The objective of an ABN is two fold; one is that it prevents a healthcare provider from having proceedures done more often than is necessary, and two it forewarns the beneficiary of potential charges so that they can make a decision fully aware that they may be liable for the cost. Please see the ABN booklet: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf from page 1: "The Centers for Medicare & Medicaid Services (CMS) implemented the Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, to inform Part B and certain Part A Original Medicare beneficiaries when Medicare may deny payment for an item or service. This booklet provides information to help health care professionals understand the Medicare requirements for when and how to issue an ABN." "An ABN, Form CMS-R-131, is a standardized notice you or your designee must issue to a Medicare beneficiary before providing certain Medicare Part B (outpatient) or Part A (limited to hospice, home health agencies [HHAs], and Religious Nonmedical Healthcare Institutions only) items or services. You must issue the ABN when: ? You believe Medicare may not pay for an item or service; ? Medicare usually covers the item or service; and ? Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance." "ABNs allow beneficiaries to make informed decisions about whether to get services and accept financial responsibility for those services if Medicare does not pay. The ABN serves as proof the beneficiary knew prior to getting the service that Medicare might not pay. If you (healthcare provider) do not issue a valid ABN to the beneficiary when Medicare requires it, you cannot bill the beneficiary for the service and you may be financially liable if Medicare doesn't pay."
Fair enough. I could have phrased it better, too.
 
I could be better with my phrasing too. probably spelling as well.

Medicare billing is complex, as is all Medical billing. For hospitals and professional billing services it requires an associates degree just to get a foot in the door. Not too long ago it was a learn as you go job.

I am fortunate in that this is what my wife does for a living. She has commented a number of times that hospitals and Dr.'s offices have to eat the cost whenver an ABN is not done or is not done exactly as Medicare requires. I am told this happens fairly often because the Dr. office or hospital admin are not aware of all the rules.

Technically, if a healthcare professional sends a bill to a Medicare beneficiary w/o the required ABN, there are possible fines up to $10,000 just for sending the bill. I expect that won't happen unless it was repeated and intentional, but it does show that CMS is serious.

Anyway, if I were the OP, I would advise my client not to pay unless they signed an ABN. They could politely remind the Dr. office of the rules or have Medicare do it for her. If they have a signed ABN, then the client should have expected the possibility of a bill.
 
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