Wiki Billing ? If Medicare is primary and we did not know it?

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insight

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So here is the scenario, I bill for a specialist private practice doctor and we do not accept medicare. We billed a patients private health insurance and the insurance paid for the visit. A few months go by and the private health insurance now wants its money back because apparently the patient had medicare at the time (through a disability) and medicare is primary.

The patient wants me to bill medicare to get the denial so I can submit to her secondary and get them to re pay.

I have never been successful in billing Medicare because we are not providers and do not have a medicare #.

HELP??
 
I believe even if you did bill Medicare and received a denial the secondary would not pay for the claim just because you are a non-par provider. You could try and appeal with the secondary insurance explaining you do not accept Medicare and was not aware of the patient's coverage status until after the fact and see if they will honor it. Otherwise, I would think it would be a loss.

Melissa Harris, CPC
 
If you documented due diligence in ascertaining the patient's health care coverage, and the patient confirmed in writing, like on a patient registration form that they only had the commercial insurance that you billed, AND if your patient registration form or other form(s) clearly indicate that ultimately the patient is responsible for providing correct insurance information and is responsible for the charges, then you may be able to collect from the patient. The form I use has this: "I understand that I am financially responsible for any and all balances, including but not limited to: co-pays, deductibles, co-insurances, out of pocket expenses, maximum benefits, or any other balances. "
 
I believe even though your physician is not a provider he must still submit the claim to Medicare on behalf of the patient so that the patient can be reimbursed for the services. Then your patient could either submit the Medicare EOB themselves to the secondary for any payment due or give you the EOB to submit to the 2ndary. Most likely, if payment was due from secondary, it too would go to the patient and not to the physician.

Unfortunately cases like these do happen either accidently or deliberately, I have never been able to figure out, but going forward it might be helpful to have a form for the patient to sign that he/she does not have Medicare coverage or coverage with any Medicare replacement plan and he/she understands that they are responsible for payment if it is discovered later that coverage existed. It probably won't eliminate these scenarios entirely but it will make you feel that you've done all you can:)

Good luck.
 
What is your physician's actual status with Medicare? Is he "non-par" or has he opted out? Your course of action will be determined by the status. If your physician has opted out of Medicare then neither he nor the patient can ever bill Medicare.
 
He opted out of medicare. I have called the secondary insurance and pleaded my case and they are "supposed to look into it for me". We will see if that goes anywhere. Fingers crossed.
 
Interesting....if Medicare denies it, depending on the denial code or usage of PR vs CO, that will determine if you get paid or not. You can appeal to the secondary insurance though. They would likely pay it but otherwise, the patient would be responsible and there should be a contract in your office's paperwork that states that. I know there is in ours. People like to play this game with us a lot.
 
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