You Be the Expert: Medicare Noncovered Services
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: Our office is having a debate on how to handle services that are not covered by Medicare. One group says to bill all services provided and adjust the charges accordingly after the carrier completes processing. The other side says bill only what is covered. Which is correct?
West Virginia Subscriber
Answer: Many billers question whether you should bill noncovered services to Medicare when youre going to end up charging the patient anyway. For services that are never covered, such as an annual physical, you should only bill Medicare under two circumstances:
1. You are seeking a denial to submit the claim to a secondary insurer that may cover the services. Medicare patients buy secondary insurance coverage expressly to pay for things Medicare does not cover. To get the claim to cross over to the secondary insurer, you should bill Medicare for the noncovered services, and the secondary will consider payment on the items Medicare did not pay.
2. The patient insists that you file a claim. Many Medicare patients have the misconception that Medicare will pay for everything, and when you tell them something is not covered, they dont believe you. For good patient relations in these cases, bill the claim.
In either case, indicate in the appropriate field of the claim the reason for the claim submission, such as need denial for secondary insurance or need denial for patient.
For services that are sometimes covered by Medicare, which occurs when a local medical review policy exists, you should have the Medicare patient sign a completed advance beneficiary notice (ABN) before any services are rendered, and then bill Medicare for those services. Many practices have the patient sign the ABN even when they know Medicare does not cover the services, and the waiver is not required. Dont assume the patient knows a service is not covered by Medicare. If you dont have patients sign an ABN, they could fight their responsibility for the bill by arguing you never notified them that they were liable for services not covered by Medicare.
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