Part B Insider (Multispecialty) Coding Alert

Make sure your patients are well-informed on their Medicare benefits.

Although much of your day is probably spent dealing with insurers, chances are strong that you’re called to answer Medicare-related questions from your patients several times a week as well. If you’re unsure of how to respond when beneficiaries are confused about their coverage, check out the following answers to five common questions that our readers have received from Medicare patients.

1. If your practice accepts assignment, why do I have to pay anything?

Answer: If a provider accepts assignment, that means it agrees to accept the Medicare payment amount for a particular item or service as its payment in full. But the patient must still pay the copayment, plus any applicable deductible.

If a patient asks what happens if they go to a practice that doesn’t accept assignment, let them know that they may have to pay more than the Medicare amount at that office, although for most services a doctor’s office can only charge up to 15 percent more than the amount Medicare usually pays. It also means that the patient may have to pay for the treatment’s full cost up-front. Then the practice will bill Medicare and send the Medicare payment to the patient, minus any copayments or deductibles.

2. I was in the hospital for three days – 24 hours in the emergency department and two days in observation. Why is my doctor refusing to approve me for a skilled nursing facility (SNF) stay?

Answer: Although the patient is correct in the knowledge that SNF coverage is only applicable to beneficiaries who are inpatients for at least three consecutive days, it doesn’t look like this patient was an “inpatient” at any point in the hospital stay. Let the patient know that Medicare classifies the emergency department and observation unit as outpatient areas, and unless he was actually admitted to the hospital as an inpatient after the physician wrote an order for that service, and then stayed for three days in a row, he won’t qualify for SNF coverage. 

The patient can ask the doctor whether he qualifies for home health care or other benefits that might help him upon his release from the observation unit.

3. I heard that Medicare started offering free annual physicals. Can I schedule mine?

Answer: Although Medicare Part B does cover an annual wellness visit (AWV) every year, those aren’t the same thing as a physical. The AWV is a preventive wellness visit and not a “routine physical checkup” that the provider might recommend. Medicare does not provide coverage for routine physical exams such as complete physicals.

Explain to the patient the difference between the AWV (which is rendered at no charge to the patient) and a preventive visit (which the patient will have to pay for in full). If the patient refuses the AWV and requests the preventive exam instead, document these details in the patient’s record.

Although an advance beneficiary notice (ABN) is not required since preventive visits are statutorily non-covered by Medicare Part B, it might be in your best interest to have such patients sign an ABN anyway. That will serve as further proof that the patients knew that they would have to pay for the visits on their own. 

4. I have a new diagnosis that requires medicine that is too expensive for me to pay out-of-pocket. I tried to enroll in Part D Medicare last month but they said I can’t change my coverage at this time. When can I change it?

Answer: If a patient wants to change any Medicare benefits, now is the time for them to do so. The open enrollment period begins on Oct. 15 and runs through Dec. 7. The coverage that the patient selects during this period will go into effect on Jan. 1, 2015. 

There are some exceptions to the annual open enrollment period requirement. For example, if the patient loses other prescription drug coverage during the year, moves out of your plan’s service area, or moves into an institution such as a nursing home, Medicare may consider a change in the patient’s benefits outside of the standard enrollment dates.

5. I want to see a specialist but my primary care doctor didn’t write me a referral. The specialist I want to see says he won’t take my Medicare. How can I get my primary care physician to write an order for the specialty service?

Answer: Medicare Part B does not require a patient to have a referral to see a specialty physician. However, that specialist must participate with Medicare for their office to accept the patient’s coverage. It sounds like this patient wants to see a specialist who doesn’t accept Medicare Part B at all. A referral won’t change that.

If, however, the patient has a Medicare Advantage (MA) plan, it’s possible that they might need a referral to see a specialist. The HMO plans that are part of the MA program do typically require specialty referrals, although the most of the PPO plans do not. 

If the patient has Part B, ask her to double check whether her preferred specialist participates with Medicare. If so, let her know that a referral should not be required. If she is on an MA HMO plan, have her discuss the potential need for a specialist with your physician so he can determine whether a referral is advisable.