Wiki IPA/HealthPlan force member to apply for Medicare

[FresnoRock]

We are a clinic. This member of a IPA/HealthPlan (our patient) young but became ESRD, there were a few Dialysis claims that were denied by the IPA/HealthPlan saying that the member should apply for Medicare; the IPA/HealthPlan rep said that their member "may" get Medicare - she herself not sure.

Facts:
[1] Nobody wants to pay for Dialysis expenses and all these private healthplan want to dump their members to Medicare.
[2] Chances are this member refuses to get Medicare for various reasons: Medicare comes with 20% coinsurance and he is currently getting the free private insurance thru his work.

Questions:
[1] Can IPA/HealthPlan compel a member to apply for Medicare?
[2] Isn't IPA/HealthPlan responsible for payment although it's suck for them?

Thanks in advance.

 

[amyjph]

This isn't really a coding type or practice question. I wouldn't suggest a provider office counsels patients on what insurance they should get or not get. That's between the patient and their plan and/or family. The family and or member would need to contact their plan and Medicare to get this figured out.

https://www.cms.gov/medicare/coordination-benefits-recovery/overview/end-stage-renal-disease-esrd

The GHP may not differentiate in the benefits it provides to individuals who have ESRD. Specifically, GHPs are prohibited from terminating coverage, imposing benefit limitations, or charging higher premiums on the basis of the existence of the individual's ESRD.

 

[sls314]

We are a clinic. This member of a IPA/HealthPlan (our patient) young but became ESRD, there were a few Dialysis claims that were denied by the IPA/HealthPlan saying that the member should apply for Medicare; the IPA/HealthPlan rep said that their member "may" get Medicare - she herself not sure.

Facts:
[1] Nobody wants to pay for Dialysis expenses and all these private healthplan want to dump their members to Medicare.
[2] Chances are this member refuses to get Medicare for various reasons: Medicare comes with 20% coinsurance and he is currently getting the free private insurance thru his work.

Questions:
[1] Can IPA/HealthPlan compel a member to apply for Medicare?
[2] Isn't IPA/HealthPlan responsible for payment although it's suck for them?

Thanks in advance.

Just adding that Medicare would be the secondary payer to the group health plan for 30 months anyhow.

From the same link that Amy provided above:

Medicare is the secondary payer to group health plans (GHPs) for individuals entitled to Medicare based on ESRD for a coordination period of 30 months regardless of the number of employees and whether the coverage is based on current employment status. Medicare is secondary to GHP coverage provided through the Consolidated Omnibus Budget Reconciliation Act (COBRA), or a retirement plan. Medicare is secondary during the coordination period even if the employer policy or plan contains a provision stating that its benefits are secondary to Medicare.