Wiki Billing Medicare after MA claim denied

[Blackhorse]

PT has both Medicare Advantage Plan and Medicare. We are OON with the MA plan and the claim is denied because of missing Auth. Just wonder if we can bill Medicare with the MA plan denial?

What if PT has Blue Cross and Medicare secondary. If Blue Cross denied claim because of medical necessity, can we bill Medicare with BC denial?

 

[sls314]

PT has both Medicare Advantage Plan and Medicare. We are OON with the MA plan and the claim is denied because of missing Auth. Just wonder if we can bill Medicare with the MA plan denial?

What if PT has Blue Cross and Medicare secondary. If Blue Cross denied claim because of medical necessity, can we bill Medicare with BC denial?

Do you mean Medicaid?

Medicare Advantage is a Medicare replacement - a patient cannot have both MA and Medicare at the same time.

In my state, Medicaid would deny the secondary claim. The patient must follow the rules of the MA plan and see an in-network provider in order for Medicaid to make a secondary payment. We had a huge problem with this at a hospital system I worked for due to one specific MA plan where we were out of network.

You'll have to check with your state's Medicaid to see if they will consider the claim for the OON MA plan.

 

[SharonCollachi]

Susan is correct, Medicare Advantage plans are Medicare REPLACEMENT plans. A person cannot have both.

If someone has dual coverage, 99.99% of the time, the secondary will follow the primary as far as decisions go with regard to claim acceptance. I have seen exactly one patient in my career successfully get their secondary to pay when they didn't follow the rules of the primary (patient had Kaiser primary and one of the Blues secondary; we are not Kaiser providers and the patient got the Blue to pay).