Wiki Billing Secondary as Primary when Provider is NON-PAR with Medicare A/B

[JSwise]

I recently took over billing accounts for a Provider, (Scenerio: Patient is established and has been seen for several years, we just found out that they had Medicare part B as Primary. In the past the office was billing the PPO insurance for services (which was/is actually the Secondary payer), and have received payment for services).
If a patient is being seen for Acupunture and Natropath services and has Medicare Part A and B as primary, and has a PPO as Secondary BUT the provider is NOT contracted with Medicare, (1) can the patient still be seen for these services? (2) Do you bill Medicare to obtain a Denial and then submit claims to Secondary? (3) Or do you submit claims directly to the secondary PPO bypassing Medicare all together since the provider is NON-PAR? (4) Should the patient be filling out a form or waiver, (ABN comes to mind but not sure), prior to services being rendered?

 

[SharonCollachi]

Not sure if you mean the provider is non-par, or if the provider hasn't registered with Medicare at all. This isn't like commercial insurance where if you don't sign a contract, you're automatically non-par with the insurance company. With Medicare, you have to still register, as non-par (or as opt-out, which is something different than non-par). If the provider has not registered at all, here are the answers:

1. Not sure that's really the question you meant to ask, of course the patient can still be seen. Billing for it is another matter.

2. You cannot bill Medicare unless you are a participating or non-participating provider. You have to register with Medicare, you cannot see a Medicare patient without registering.

3. In my career, I have seen one secondary that paid without the primary processing the bill, only because the patient harrassed them. I think they did it to shut her up. In your case, the provider is NOT non-par, so you can't bill Medicare.

4. A form isn't going to help you, because see #2.

If instead, the provider is non-par (registered with Medicare as a non-par provider, here are your answers:

1. Same.

2. Bill Medicare, they will process as non-par, and you will forward the claim to the secondary.

3. No, see #2.

4. ABN is applicable to tell the patient what you believe their financial responsibility is when something isn't covered. You should definitely make sure the patient knows that you (the physician) are not participating and what that means.