# Medicare Advantage plans denying annual gyn exams and cannot bill the patient???



## jwitt18# (Jun 10, 2016)

We have had many Medicare Advantage plans deny the annual gynecological exam as "benefit max reached" "you cannot bill the patient".  Aetna Medicare allows a gynecological exam once every 24 months, if the patient comes in early the insurance "normally" denies the claim and makes it patient responsibility.  What has changed? We now have the insurance not paying and the patient not being responsible to pay. The doctors should not have to provide services for free!! Has anyone else had this issue?  Any advice is greatly appreciated!!!


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## ljjulian (Jun 10, 2016)

What codes are you using?


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## jwitt18# (Jun 10, 2016)

We are using the preventive medicine codes 99387 or 99397 with Dx Z01.419 and Z12.4 (if a pap was done). We have even coded as Medicare requires such as: 99397, G0101 and Q0091 but then they try to bundle the G0101 and Q0091 to 99397.


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## brianasteuck (Jun 18, 2016)

May want to check with each of those payers to see if you were to give the ABN if they would then hold the patient responsible.


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## mitchellde (Jun 18, 2016)

If it is a Medicare patient and it is a time limitation such as this, then you are required to obtain an ABN stating that the patient knows the required amount of time has not lapsed and then you attach the GX modifier to the service.  The GX modifier will have the affect of have the EOB tell the patient they owe the provider.


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## r78tweety (Jan 11, 2018)

Has anyone followed up on this & has using an "ABN" worked with getting the CO119 changed to PR119???  

Thank you in advance for your response. 

Robin


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## medavis619 (May 15, 2019)

*"ABN" and GX modifier with Aetna Medicare*

Per a rep at Aetna Medicare you cannot use the Medicare ABN or even a general waiver, I have tried the GX modifier and GY and it does not change the denied claims to patient responsibility. Our office is struggling with a solution for this as we cannot see these patients for free! Does anyone have any other input on this issue?


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## thomas7331 (May 15, 2019)

medavis619 said:


> Per a rep at Aetna Medicare you cannot use the Medicare ABN or even a general waiver, I have tried the GX modifier and GY and it does not change the denied claims to patient responsibility. Our office is struggling with a solution for this as we cannot see these patients for free! Does anyone have any other input on this issue?



If your provider is contracted with this advantage plan, then you will need to abide by the terms of the contract, and there may be a clause that does not allow you to bill patients for non-covered services.  If so, you may wish to discuss this with your provider representative - if it is not in the contract, then the reps should not be telling you this, but if it is, then you may want to considering renegotiating the terms when you renew.  However, if you are not contracted with the plan, then per my understanding you are not required to accept the terms of the plan, provided that it is not an emergency situation and that you give ample advance notification to the patient that you do not accept this plan.


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