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Re: Medicare HMO question
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SMVerno
Re: Medicare HMO question
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Jun 11 07 9:57 AM
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It's not as simple as that. You see, if your provider was not contracted with the patient's HMO and agreed to treat the patient without talking to the patient and without contacting the HMO to see if authorization was required, then the doctor has to accept responsibility for his actions.
Actually, you may not be able to bill the Medicare HMO patient unless the HMO denies the claim for no coverage or for non-par reasons. Unless you have seen the patient's benefit manual, you don't know if the patient is responsible for charges when they go out of network. Not all Medicare HMOs have the same policies.
If you haven't submitted the claim, then you need to do so. If they denied the claim, then look at the reason for the denial. If the denial is because the services were rendered by a non-par provider, then you could bill the member. If the HMO pays, all they have to pay is the Medicare fee, including copays and dedictibles.
United and Aetna have sent letters to all non-par providers stating that they will no longer send payment to the non-par provider. How I handle these is I have informed Aetna and United that I will no longer send claims as a courtesy to their member. Their members must pay my provider 100% of billed charges and the member can send their own claims.
Be careful on these "contracts" you are signing. The insurance company could take this to mean you have now contracted to be paid at the agreed upon rate for all products and all affiliates. I only give a discount when I receive payment within 5 calendar days of the signing of the agreement, and even then, if the agreed payment is not received within 5 days, the agreement is terminated and 100% of charges is to be paid. I also state that the agreement is for this claim and this date of service only.
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Association News
Medical Billing & Coding Education from the MAB
Continuing Education
Management Advice and Training
Questions Asked More Than Once
Help Wanted - Billing and Coding
Non Billing Talk
The Venting Area (Clean posts please)
Medical Coding and Billing News
Fraud and Abuse
Health Insurance - Provider Contracting
ERISA
Tricare
Workers' Compensation
General Medical Billing Questions
Appeals
Accounts Receivables (A/R)
Refunds
Auto Accident Issues
Medisoft Technical Support
Medical Software Technical Support Questions Other than Medisoft. No Investigation Questions!
General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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