Neurology & Pain Management Coding Alert

Question: Our physician saw a patient in the hospital. The patient had Medicare Part A coverage and had an HMO as her secondary insurer. Medicare Part A does not cover physician services, so we billed the HMO for his work. The HMO refuses to pay and tells us to bill the primary insurer first. What should we do?

Georgia Subscriber Answer: Track down a claims representative at the HMO and tell him that the patient only has Medicare Part A, which does not cover physicians- services in the hospital -- and that's why you billed the HMO first. The HMO insurance company is technically the -primary- payer for the hospital service.

If the HMO still refuses to pay, consider submitting the claim to the patient's Part A insurer (Medicare) just so you can get the denial. Then bill the HMO again for the service, including a copy of the Medicare denial. Explain that the physician's service was not covered by the patient's primary insurer (Medicare) and that you are therefore requesting payment for his work through the HMO. Clinical and coding expertise for You Be the Coder and Reader Questions  provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher.