Wiki Deana

[deanaTuorto1!]

I recently received a remittance from Noridian Medicare (Hawaii) Part B. One of the claims that was processed on the remit had an additional adjustment I had never encountered previously. This patient has a dual plan. Medicare/Medicaid. Enrolled with straight Medicare and has HMSA (BCBS of Hawaii) Quest as the secondary.


8/28/2017 8/28/2017 1 99212 $129.00 $46.60 $0.00 $0.00 $0.00 $35.80 $81.45 CO-45
$1.70 CO-237
$0.73 CO-253
$9.32 OA-209 N699, N701, N782
SERVICE LINE TOTALS: $129.00 $46.60 $0.00 $0.00 $0.00 $0.00 $93.20 $35.80

OA-209 : Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA) Start: 07/09/2007 | Last Modified: 07/01/2013

Usually the $9.32 would be PR-2 patient coinsurance.

When I contacted Noridian to inquire about the adjustment; stating that the patient has a secondary and why is the $9.32 listed with this adjustment instead of being PR-2?: the rep explained that Medicare is now using this code when a member has a dual plan to let the provider know they need to write off the coinsurance if they do not submit to the secondary.

I use an automated system that electronically uploads and posts remittances. It is adjusting this as it should because that is how Medicare is coding it - as an adjustment. Why has Medicare changed this? Why can't they use a different non adjustment code that wont auto adjust? How do we get around this? Has anyone else experienced this issue and do they have a solution?

 

[honeybee]

This is a new thing that medicare is doing, we are running into it as well. The patient must have a state medicaid plan in effect so they are automatically adjusting off the coinsurance to ensure the patient is not billed. Apparently there has been a big issue with providers holding patients responsible for the coinsurance when it is not appropriate so they have implemented this rule . Most of the members we have this happening with we show their medicaid plan on file as their 2nd ins but we have a few patients that we were never made aware they even had medicaid until this started to happen. Once we saw the adjustments and checked our state database we were able to confirm the patient is dual eligible/QMB status. It sounds like this particular patient you mentioned must have a 3rd ins with medicaid that you are not aware of. We have found that claims will still cross over to the secondary if applicable and pay and you can still submit manually to the 2nd ins if needed. We basically have to watch for this adjustment code while posting the ERA and then manually remove the adjustments so we can bill the 2ndary plan since some of our state medicaid plans will still pay a portion or all of the remaining coinsurance depending on our allowable. In some cases this is a benefit to us as we wouldn't have been paid by the medicaid plan anyways since medicare's allowable exceeds the medicaid plan allowable. We have made numerous calls and been told that we are not the only providers frustrated by this. I get why the are doing it but if we don't catch these adjustments we could miss billing for additional balances that may be due to us.

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/se1128.pdf

I believe your mac is Noridian, here is the MLN matters article

 

[daedolos]

Query

Why does the remittance advice say to refund the patient if payment collected from the secondary?

Peace
?_?