Anesthesia Coding Alert

Question: Our pain management specialist saw a patient in the hospital. The patient had only Part A Medicare coverage and had an HMO as her secondary insurer. Medicare Part A does not cover physician services, so we billed the HMO for his work. But the HMO refuses to pay and tells us to bill the primary insurer first. What should we do?

Georgia Subscriber

Answer: You'll have to track down a contact at the HMO and talk to him over the phone. Tell the claims representative that the patient only has Medicare Part A, which does not cover physicians' services in the hospital, and that's why you billed the HMO first. The HMO insurance company is technically the "primary" payer for the hospital service.

If the HMO still refuses to do business with you, consider submitting the claim to the patient's Part A insurer (Medicare) just so you can get the denial. Then bill the HMO again for the service, including a copy of the Medicare denial. Explain that the patient's primary insurer (Medicare) did not cover the physician's service and that you are therefore requesting payment for his work through the HMO.

Other helpful tactics: Have a copy of the patient's Medicare identification card so you can show it to the carrier in question. Also keep the patient updated on the situation, and ask her to talk with the carrier representative if necessary.