Q: When is it acceptable to collect the deductible from the beneficiary?

This is the most sighted question from provider.


A: When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable - and over-collection is considered program abuse - do not collect these amounts until you receive Medicare Part B payment.

• If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.)


• Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.


How is the Medicare Part B annual deductible applied to payment?

A. For each calendar year, a certain cash deductible exists that must be met before payment may be made by Medicare.

• The deductible for 2013 and 2014 is $147.00.

Patient expenses are applied toward the deductible based on incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible.
If an individual does not have Part B benefits for an entire calendar year (i.e., insurance coverage begins after the first month of the year), he or she is still subject to the full deductible for the calendar year. Medical expenses they incurred during the year, but before they are actually entitled to Medicare, cannot be applied to the deductible.
Although the date of service generally determines when expenses were incurred, the order in which expenses are applied to the deductible is based on when the bills are actually received.

• Note: Services not subject to the deductible cannot be used to satisfy the deductible.

Billing Medicare - Medicaid patient . Explanation of different Medicaid plan and its coverage

Dual Eligible Beneficiaries

Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B and one of the following Medicaid Programs:

• Full Medicaid; or
• Special Need Plans, which include the following four programs:
○ Qualified Medicare Beneficiary (QMB) Program;
○ Specified Low-Income Medicare Beneficiary (SLMB) Program;
○ Qualifying Individual (QI) Program; and
○ Qualified Disabled Working Individual (QDWI) Program.

Dual eligible beneficiaries may choose coverage under FFS Medicare or a MA Plan. Medicare-covered services are paid first by Medicare because Medicaid is always
the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover

Full Medicaid

Its coverage either categorically or throught optional coverage groups based on medically need status. Special income levels for institutionalized individuals or home and community based waivers

Medicaid pays for part A and part B premiums and cost sharing for Medicare providers to the extent consistent with Medicaid state plan

QMB Only

Medicaid pays for part A AND Part B premiums, deductibles, coinsurance and copayments for Medicare services furnished by Medicare providers to the extent consisten with Medicaid state plan

SLMB Only
• Medicaid pays for Part B premiums

Prohibited Billing
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).

We could only bill patient if they SLMB plan.

Can we bill patient when Medicare claim denied as timely filing?

Medicare document says yes but only limited to Deductible and coins.


Determination of Untimely Filing and Resulting Actions


Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal.


Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. In appropriate cases, such claims should be processed because of the spell-of-illness implications and/or in order to record the days, visits, cash and blood deductibles. The beneficiary is charged utilization days, if applicable for the type of services received.

Can we submit the claim if patient has provided the backdated card , what is the time limit for secondary claims

Backdated Medicaid Cards 

If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card.  Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.  

Example:  Services rendered by a physician on 3/1/2012; on 6/1/2012, member‟s Medicaid eligibility is granted effective 3/1/2012.  All services previously rendered after 3/1/2012 can be billed to Medicaid, and considered for reimbursement if claims are received by 6/1/2013.


MCO‟s and Timely Filing 

Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible.  In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service. Please Note: The MCO must be one of the MCO‟s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.

To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions below for Medicare primary claims and backdated medical card.)

The original claim must have had the following valid information:
•   Valid provider number
•   Valid member number
•   Valid date of service
•   Valid type of bill

Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.

This policy is applicable to reversal/replacement claims.  If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing.

Medicare Primary Claims/Secondary Claims 

Timely filing requirement for Medicare primary claims is one year from the EOMB date. Did you know that secondary claims can be submitted electronically? For more information, please call our EDI help desk at 888-483-0793, option 6.

How much is Medicaid copay - out of pocket and what are the exemption cases

Beginning January 1, 2014, some services will be assigned copay amounts for Medicaid Members. The following copays will apply to claims with a date of service on or after January 1, 2014:

Service TIER 1 Up to 50.00% FPL   TIER 2 50.01-100.00% FPL     TIER 3 100.01% FPL and above 

Inpatient Hospital (Acute Care 11x)  --- $0  $35  $75

Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care)                                ---  $0  $2  $4


Non-Preferred Drugs ----  $2  $4  $8

Non-Emergency use of Emergency Department - Hospital only  (Lowest level (99281) of Emergency Room visits in hospitals.  The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.)  ---------- $8  $8  $8

Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0  $2  $4


Maximum Out of Pocket (OOP): 

Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment.  The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received.  The following table shows the OOP for each tier level.

Tier Level  Out of Pocket Maximum 
1  (Up to 50.00% FPL)  $8
2 (50.01-100.00% FPL)  $71
3 (100.01% FPL and above)  $143

Quarters 
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014

Exemptions: 
The following populations and services are exempt from copays:
  Pregnant Women including pregnancy-related services up to 60 days post-partum;
  Children under age 21;
  Native American and Alaska natives;
  Intermediate Care Facility or MR services;
  Preventive services for children under age 18;
  Provider-preventable services;
  Individuals in Nursing Homes,
  Receiving Hospice services,
  Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
  Family Planning services and Emergency services.  

Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.

Charges for Missed Appointments

CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments.  The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity.  Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.

The amount that the physician or supplier charges for the missed appointment must apply equally to all patients (Medicare and non-Medicare), in other words, the amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients (whatever amount that may be).

With respect to Part A providers, in most instances a hospital outpatient department can charge a beneficiary a missed appointment charge without violating its provider agreement and 42 CFR 489.22.  Because 42 CFR 489.22 applies only to inpatient services, it does not restrict a hospital outpatient department from imposing charges for missed appointments by outpatients.  In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee.

Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers.  Charges to beneficiaries for missed appointments should not be billed to Medicare.

If contractors receive any claims for missed appointment charges, the following reason code and MSN messages should be used to deny the claims—

Reason Code 204: This service/equipment/drug is not covered under the patient’s current benefit plan.
MSN messages:
16.59 - Medicare doesn’t pay for missed appointments.
16.59 – Medicare no paga por citas médicas a las que no se presentó.

Do we need show the amount collected from patient in CMS 1500 form?

By law, yes. we should show the it in the form and infact that reduce physician work of refunding the excess payment and other work related on that process.

Failing to do so and medicare receives many complain that leads the unwanted audit process.

Showing the Amount Collected on the Claims Form  

In submitting an assigned claim, the provider (including physicians and suppliers) must show on Form CMS-1500 any amount he/she has collected from the enrollee for these services.  This information is essential for correct payment of the benefits due; failure to show the amount paid is likely to result in excessive benefit payment to the provider (including physicians and suppliers) (i.e., a benefit payment which, when added to the amount already paid by the enrollee, will exceed the Medicare allowed amount).

EXAMPLE:  The physician accepted assignment of a bill of $300 for covered services and collected $60 from the enrollee, but failed to show on the claim form that he/she had collected anything.  The carrier determined the Medicare allowed amount to be $250, and since the deductible had previously been met, made payment of $200 to the physician.  Since the physician would have received $190 in benefit payments and the enrollee $10 if the amount collected had been shown on the claim form, the physician has been overpaid $10.  When this overpayment comes to light, e.g., by a complaint from the enrollee, the carrier will take necessary corrective action, e.g., advise the physician to refund the $10 to the enrollee and if he/she fails to do so, pay the enrollee the $10 and recover the overpayment from the physician.

What happen to the claims if accept assignment is not marked in participating provider claims?

Processing Claims for Services of Participating Physicians or Suppliers by Carriers 

The participating physician or supplier submits any claims for services furnished by the physician or supplier, except in the limited circumstances specified in §30.2.8.3 or §30.2.16.  (The exception concerns situations where the physician or supplier accepts, as full payment, payment by certain organizations.)  When an unassigned claim is received from a physician, the carrier must verify that the physician is participating.  The carrier processes the claim as assigned absent clear evidence of intent by the physician or beneficiary not to assign.  The following message must be printed on the remittance advice:
We believe you inadvertently submitted this claim as unassigned.  As a participating physician, you agree to accept assignment on all claims.  We are, therefore, processing this claim as assigned.

Any Form CMS-1500 claim where the participating physician or supplier checks either the assignment or non-assignment block or fails to check either block, the carrier must treat it as assigned.

Where there is evidence of clear intent not to assign, the carrier must deny the claim.  Use MSN 16.6.
“This item or service cannot be paid unless the provider accepts assignment.

Carriers must identify and track assignment violations in the event sanctions must be imposed.

No Part B payment is made on a claim by a participating physician or supplier to anyone other than the physician or supplier (except in the case of court-ordered assignment to other parties under §30.2) even if the beneficiary has paid part of the bill.  However, if the physician or supplier collects any charges from the beneficiary before submitting the claim, he/she must show on the claim form the amount collected.  The carrier refunds directly to the beneficiary, to the extent feasible, any over collection of deductible and coinsurance.  The physician is responsible for refunding to the beneficiary any over collection not refunded by the carrier directly.  In these latter instances, the carrier advises the physician of his/her obligation to refund any over collections to the beneficiary.  Also, the carrier advises the beneficiary of the amount of any refund due from the physician.

How much amount can physician collect from patient before the service rendered?

 Physician’s Right to Collect From Enrollee on Assigned Claim Submitted to Carriers 

 Before the Claim is Submitted
The provider (including physicians and suppliers) who is accepting assignment should not attempt to collect more than 20 percent of the charge from the enrollee when the deductible has been met.  He or she should, if the occasion arises, be advised not to do so. Any greater amount collected will:

1. Reduce the amount payable to him/her on the assigned claim,
2. Cause the enrollee unnecessary hardship in raising the excess amount, and  
3. Require extra work for the carrier in paying this excess to the enrollee instead of the physician.
 
However, a provider (including physicians and suppliers) may accept assignment after having collected a part of his/her bill.  The fact that the enrollee has paid more than any deductible and coinsurance due does not invalidate the assignment.


 Durable Medical Equipment Supplier Bills for Coinsurance at the Time Claim Submitted
 
Notwithstanding the guideline in C above, a supplier of durable medical equipment may bill the beneficiary for 20 percent of the Medicare allowed amount at the same time it submits an assigned claim to the carrier for the items and services furnished.  The supplier must undertake:

1. To bill the beneficiary at the time it submits the claim only for 20 percent of the Medicare allowed amount; and

2. To inform the beneficiary prominently on its invoice that:
a. It has submitted a claim to the carrier for the items and services and he/she should not him/her self submit such a claim; and
b. The bill is for 20 percent of the Medicare allowable charge and is not covered by Medicare; and

3. To establish and maintain adequate procedures for refund of any over collections from the beneficiary that might result from the carrier approving a different Medicare allowed amount than that submitted.

Can provider collect Medicare deductible upfront?

Yes, we could collect the payment but it has to be refunded promptly if you are collecting excess payment or collected incorrectly. See the below what says in Medicare contract.

Yes its a good practice too improve patient payment collection.

 Provider Refunds to Beneficiaries 

In the agreement between CMS and a provider, the provider agrees to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.

Money incorrectly collected means any amount for covered services that is greater than the amount for which the beneficiary is liable because of the deductible and coinsurance requirements.

Amounts are considered to have been incorrectly collected because the provider believed the beneficiary was not entitled to Medicare benefits but:

• The beneficiary was later determined to have been entitled to Medicare benefits;

• The beneficiary’s entitlement period fell within the time the provider’s agreement with CMS was in effect; and

• Such amounts exceed the beneficiary’s deductible, coinsurance or non covered services liability.



Requiring Prepayment as a Condition of Admission is Prohibited

Providers must not require advance payment of the inpatient deductible or coinsurance as a condition of admission. Additionally, providers may not require that the beneficiary prepay any Part B charges as a condition of admission, except where prepayment from  non-Medicare patients is required. In such cases, only the deductible and coinsurance may be collected.

When Prepayment May Be Requested

he provider may collect deductible or coinsurance amounts only where it appears that the patient will owe deductible or coinsurance amounts and where it is routine and
customary policy to request similar prepayment from non-Medicare patients with similar benefits that leave patients responsible for a part of the cost of their hospital services. In  admitting or registering patients, the provider must ascertain whether beneficiaries have medical insurance coverage. Where beneficiaries have medical insurance coverage, the provider asks the beneficiary if he/she has a Medicare Summary Notice (MSN) showing his/her deductible status. If a beneficiary shows that the Part B deductible is met, the provider will not request or require prepayment of the deductible.

Except in rare cases where prepayment may be required, any request for payment must be made as a request and without undue pressure. The beneficiary (and the beneficiary’s family) must not be given cause to fear that admission or treatment will be denied for failure to make the advance payment.

Providers must insure that the admitting office personnel are informed and kept fully aware of the policy on prepayment. For this purpose, and for the benefit of the provider and the public, it is desirable that a notice be posted prominently in the admitting office or lobby to the effect that no patient will be refused admission for inability to make an advance payment or deposit if Medicare is expected to pay the hospital costs.


Guide for Patient


What you pay

For most services, you (or your supplemental coverage) pay the following:

• The yearly Part B deductible if you haven’t already paid it for the year.

• A copayment amount for each service you get in an outpatient visit. For each service, this amount generally can’t be more than the Part A inpatient hospital
deductible. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.
• All charges for items or services that Medicare doesn’t cover.

Example: Mr. Davis needs to have his cast removed. He goes to his local hospital outpatient department. The hospital charges $150 for this procedure. His copayment amount for this procedure, under the outpatient prospective payment system, is $20. Mr. Davis has paid $85 of his $155 Part B deductible. To have his cast removed, Mr. Davis must pay $90 ($70 remaining deductible amount + $20 copayment amount).

The amount you pay may change each year. The amount you pay may also be different for different hospitals.

Note: If you have a Medigap (Medicare Supplement Insurance) policy, other supplemental coverage, or employer or union coverage, it may pay the Part B deductible and copayment amounts.


If you paid more than the amount listed on your Medicare Summary Notice

After Medicare gets a bill from the hospital, you will get a Medicare Summary Notice. This notice will show how much you have to pay for the services you got. It will also show how much Medicare paid the hospital for the services. If the amount you paid the hospital or community mental health center at the time of service is more than what was listed on the Medicare Summary Notice, call the provider and ask for a refund. Tell them you paid more than the amount listed on the Medicare Summary Notice.

If you paid less than the amount listed on your Medicare Summary Notice

If you paid less than the amount listed on your Medicare Summary Notice, the hospital or community mental health center may bill you for the difference if you don’t have another insurer who is responsible for paying your deductible and copayments.



MEDICAID DEDUCTIBLE BENEFICIARIES AND MSP

Beneficiaries may be a MSP and also a Medicaid deductible beneficiary. The beneficiary will have a Benefit Plan ID of QMB until the deductible amount has been met. The Benefit Plan ID will change to MA once the deductible amount is met. For this Medicaid eligibility period, Medicaid reimburses the provider for Medicaid-covered services, as well as the Medicare coinsurance and deductible amounts up to the Medicaid allowable.

If Medicare covers the service, the provider may bill Medicaid for the coinsurance and deductible amounts only. For any Medicare noncovered services, the beneficiary should obtain proof of the incurred medical expense to present to the MDHHS worker so the amount may be applied toward the beneficiary's Medicaid deductible amount.

What are the cases can medicare provider bill the patients?

 Provider Charges to Beneficiaries 

In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for which the beneficiary would have been entitled to have payment made had the provider filed a request for payment.

The provider may bill the beneficiary for the following items:
• Part A deductible;
• Part B deductible;
• First 3 pints of blood, which is called the blood deductible (if there is a charge for blood or the blood is not replaced);
• Part B coinsurance;
• Part A coinsurance; or
• Services that are not Medicare covered services.

SNFs may not require, request, or accept a deposit or other payment from a Medicare beneficiary as a condition for admission, continued care, or other provision of services, except as follows:

• A SNF may request and accept payment for a Part A deductible and coinsurance amount on or after the day to which it applies.
• A SNF may request and accept payment for a Part B deductible and coinsurance amount at the time of or after the provision of the service to which it applies.
• A SNF may not request or accept advance payment of Medicare deductible and coinsurance amounts.
• A SNF may require, request, or accept a deposit or other payment for services if it is clear that the services are not covered by Medicare and proper notice is provided. See Chapter 30 for instructions about ABNs and demand bills.
• SNFs, but not hospitals, may bill the beneficiary for holding a bed during a leave of absence