Wiki Medicare advantage plan deny for no referral

[cleanclaims]

Our patient has a Medicare Advantage plan and she did not notify us of the change in insurance. Our claims are now being denied as not having a referral and they denied them to the provider to write off. We are not contracted with this MAO. Does anyone have any documentation they could point me to that we, as non-contracted providers do not have to write off their charges? Thanks

 

[danskangel313]

Our patient has a Medicare Advantage plan and she did not notify us of the change in insurance. Our claims are now being denied as not having a referral and they denied them to the provider to write off. We are not contracted with this MAO. Does anyone have any documentation they could point me to that we, as non-contracted providers do not have to write off their charges? Thanks

If the claim denied to the provider, you can't bill the patient.

I realize the patient has a Part C plan, but is there a reason why insurance verification/MSP wasn't completed prior to the visit? It's always been my understanding that this is required for every encounter. Although the patient did not notify you of the change in insurance, CMS makes it the provider's responsibility to find out for themselves. In turn, if the provider doesn't check the patient's coverage, they are also liable for denials regarding authorizations and referrals.

(Using a paper HCFA-1500 for example, Item 11)
"Medicare: This item is required by Medicare.
By completing this item, the physician/ASC acknowledges having made a good faith effort to determine whether Medicare is primary or secondary. If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to items 11a–11c. This is determined by having the patient complete the Medicare Secondary Questionnaire. Items 4, 6, and 7 must also be completed."

If you could prove the patient intentionally mislead you about their insurance, then you could possibly make a case against them.