Wiki Correct GA modifier usage

AlisonFaught

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Our clinic just received a letter from an insurance company (Wellcare) stating that they are going to recoup all the money they have paid on the prevnar 13 vaccine (90670) over the past 2 years and their reason is that we used modifier GA with that code. "Pmnt Reversal-processing error-pd a non-covered benefit. Per CMS, claim lines billed with GA, GY, GZ are not payable." We have always gotten an ABN signed for this vaccine because it is a once per lifetime benefit and often times the beneficiaries cannot recall if they've had it (or if it has been a year since their once/lifetime pneumonia 90732 vaccine). Were we incorrect to use the GA modifier with this vaccine per CMS guidelines? The only CMS guideline I can find is from 2011 and it states that the GA modifier must be used when physicians want to indicate that they expect Medicare to deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. Is there a newer guideline I don't know about?
 
Is this a Medicare Advantage plan? According to CMS's guidance on ABN usage, ABNs are not for use with Medicare Part C, so logically you wouldn't expect the associated ABN modifiers to be recognized either. Maybe Wellcare is just finally getting around to correcting that error in their claims system. I would suggest contacting a Wellcare representative for more information. Maybe you'll be allowed to resubmit the claims without the GA modifiers?
You can find the info from CMS regarding ABN usage & Medicare Advantage plans here:
Medicare Claims Processing Manual- Chapter 30 - Financial Liability Protections- You can either search for "Medicare Advantage" within the document or look at page 38.
 
Is this a Medicare Advantage plan? According to CMS's guidance on ABN usage, ABNs are not for use with Medicare Part C, so logically you wouldn't expect the associated ABN modifiers to be recognized either. Maybe Wellcare is just finally getting around to correcting that error in their claims system. I would suggest contacting a Wellcare representative for more information. Maybe you'll be allowed to resubmit the claims without the GA modifiers?
You can find the info from CMS regarding ABN usage & Medicare Advantage plans here:
Medicare Claims Processing Manual- Chapter 30 - Financial Liability Protections- You can either search for "Medicare Advantage" within the document or look at page 38.

Well shoot. Yes, it is a medicare replacement. Thank you for the link - it's nice to have it in black and white. We will be calling a customer service representative to see if they can be resubmitted, but I bet they will just deny them due to outside timely filing. In the event of a denial, maybe we will be able to bill the patients and get some of that money back.
 
No problem! Good luck, I hope you can get some of that money back!
Do you mind if I ask you a follow up question? What should we do in the future to get paid for services that are not deemed medically necessary provided to patients with medicare replacement plans? For example, a beneficiary received a prevnar 13 vaccine somewhere else, forgot about it, and then had one at our clinic? Would the RA from the insurance company assign liability to the patient in that instance even though the patient had no advanced notice of potential non-payment?
 
Generally, as long as you have informed, written consent (basically an ABN or something to that effect) on file that says the patient may be held responsible if services are deemed not medically necessary, then you can usually bill the patient for the balance. Medicare Advantage plans just don't require the CMS standard ABN form or accept the ABN modifiers on charges. Since you're planning on speaking to a customer service rep anyways, double check with them, but I would think that you'd be able to bill the balance in those cases.
 
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