Hospice Billing-Medicare Advantage Plans

kamkole

Networker
Messages
25
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0
We're getting hospice claims denied by some of the Medicare Advantage Plans and need help! We've been told several different things and need clarification.

First case: We billed Sterling, but didn't know the patient was on hospice when we originally submitted the bill and they denied saying not covered because patient was enrolled in hospice. In this case, our physician was listed as the attending physician and the patient was seen for a non-hospice related illness. We thought we should bill Sterling for the services and add modifer GW to the 99213 code. Sterling says they won't pay for this and it should go to the patient's Medicare plan. Is this correct?

Second case: We billed Sterling and it was denied for the same reasons as the above case. The only difference here is the diagnosis was hospice related. The attending was our physician. Should this go to Sterling with the GV modifier or go to Medicare?

We would appreciate any help on this confusing subject!!!
 

rthames052006

True Blue
Local Chapter Officer
Messages
1,905
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York, Pa
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We're getting hospice claims denied by some of the Medicare Advantage Plans and need help! We've been told several different things and need clarification.

First case: We billed Sterling, but didn't know the patient was on hospice when we originally submitted the bill and they denied saying not covered because patient was enrolled in hospice. In this case, our physician was listed as the attending physician and the patient was seen for a non-hospice related illness. We thought we should bill Sterling for the services and add modifer GW to the 99213 code. Sterling says they won't pay for this and it should go to the patient's Medicare plan. Is this correct?

Second case: We billed Sterling and it was denied for the same reasons as the above case. The only difference here is the diagnosis was hospice related. The attending was our physician. Should this go to Sterling with the GV modifier or go to Medicare?

We would appreciate any help on this confusing subject!!!
In your first scenerio if the the pt was not seen for the hospice dx you should bill the health plan, but you should also send a copy of the hospice denial and use the GW modifier, you may have to fight this one because some of these advantage plans are clueless.

2nd scenerio if the pt was seen for the hospice dx and your doc is the attending doc on record with hospice, hospice should be paying for this service, you may have to call the hospice and talk with the appropriate source.

Our docs see alot of pt 's that go on hospice but our docs are not the attending on file with the hospice so the majority of our claims get paid thru medicare and we have no problems as long as we are using our modifiers correctly, a few years ago that wasn' the case but it's going pretty good now.

Hope this helps,

R. Thames, CPC
 
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