Last Modified: 10/30/2018 Location: FL, PR, USVI Business: Part B
What SPOT Can Do For You
"With our snowbirds, we have to stay on top of their eligibility status," said one Medicare billing manager who uses First Coast's SPOT to access eligibility information. "Having fast access to Medicare eligibility and secondary payer information helps us file clean, accurate claims and get reimbursed sooner."
Click here to find out what SPOT can do for you?
Medicare replacement FAQ
Q: For a patient not enrolled in traditional Medicare Part B but enrolled in a Medicare replacement, can a participating Part B provider ask for payment at the time of service (at the standard Medicare fee schedule rate) and instruct the patient to file the claim with the Medicare replacement for direct reimbursement? Regarding traditional Medicare vs. Medicare Advantage (MA) plans, what fee schedule can we bill?
A: If the patient is enrolled in a Medicare Advantage (MA) plan, contact the MA prior to rendering services to determine what amount he or she is responsible for paying out of pocket. This information will provide you with guidance on whether to treat and/or bill the patient. Medicare does, however, limit the amount providers can bill patients for services. For more information, please refer to Medicare & You 2018 .
When a patient enrolled in a MA plan uses out-of-network providers, their out of pocket expenses for covered services may be higher. It is important to verify with the patient [and confirm through First Coast’s Part B Interactive Voice Response (IVR) system at 1-877-847-4992 or through SPOT (Secure Provider Online Tool) if the patient is enrolled in an MA.
The Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Publication 100-16, Services of non-contracting providers and suppliers, Chapter 4 - Benefits and Beneficiary Protections states:
• MA plans must reimburse non-participating providers for emergency care, ambulance services sought through 911 calls, and for medically necessary dialysis services from a non-participating provider when the patient is out of the service area.
The CMS IOM Publication 100-16, Services of non-contracting providers and suppliers, Chapter 6 - Relationships with Providers further states:
• Non contracted providers must accept as payment in full no amount greater than what original Medicare would pay and cannot bill the patient more than their normal cost-sharing amounts (coinsurance).
There are numerous potential scenarios and the answer may change dependent upon terms of the plan. In general, if an MA enrollee seeks care outside of the MA plan in which he/she is enrolled and the Medicare Advantage organization (MAO) sponsoring the MA plan has no legal liability for reimbursement, then yes, the provider can bill the MA enrollee. The provider should not bill the MA enrollee more than the original Medicare amount for what would otherwise be covered A/B services.
There is no specific guidance for collecting payment from the patient at the time services are rendered.
Source: CMS IOM Publication 100-16, Chapters 4 and 6
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