Wiki Medicare and VA benefits compliance question

[JillMedicalBiller]

Hello!
I've recently been made aware of an issue, where a patient has been getting CGM supplies from Medicare, but also using VA benefits to get the same supplies. Basically doubling up on the supplies. My understanding is that a patient who has Medicare and VA benefits can choose between Medicare and VA benefits for a given service. However, this case sounds as if the patient was using both to get double the supplies. This sounded like a potential issue and I was just wondering if any of you have dealt with this before and what are the appropriate steps to take? The patient has told our staff that he will no longer be getting supplies from us and just going through the VA.
Thank you very much for any input on this! I appreciate it!

 

[JillMedicalBiller]

Thank you! I really appreciate your input on this!

The veteran is paying Medicare premiums, just like all other Medicare enrollees. How can he not be entitled to benefit from something he is paying for? This is not an ethical dilemma; for example, having a VA provider and a non-VA provider both prescribe narcotics and not informing either provider.

In this case, a veteran sees a VA provider who prescribes CGM supplies, and the VA fills it. He then uses his Medicare coverage, which he pays for, to see a non-VA provider, and the non-VA provider also prescribes CGM supplies.

Nothing wrong with it, whatsoever.

I’m sure the veteran has a legitimate reason for going outside the VA for CGM supplies. I imagine it’s not free, i.e., co-pays and so forth. It’s possible the veteran had a negative past experience obtaining his supplies through the VA, so he resorted to going outside the VA, spending money and using his Medicare to obtain the supplies. Maybe he ran out of his supplies before because the VA did not refill or renew his prescription in a timely manner.

 

[CBLENNIE]

The veteran is paying Medicare premiums, just like all other Medicare enrollees. How can he not be entitled to benefit from something he is paying for? This is not an ethical dilemma; for example, having a VA provider and a non-VA provider both prescribe narcotics and not informing either provider.

In this case, a veteran sees a VA provider who prescribes CGM supplies, and the VA fills it. He then uses his Medicare coverage, which he pays for, to see a non-VA provider, and the non-VA provider also prescribes CGM supplies.

Nothing wrong with it, whatsoever.

I’m sure the veteran has a legitimate reason for going outside the VA for CGM supplies. I imagine it’s not free, i.e., co-pays and so forth. It’s possible the veteran had a negative past experience obtaining his supplies through the VA, so he resorted to going outside the VA, spending money and using his Medicare to obtain the supplies. Maybe he ran out of his supplies before because the VA did not refill or renew his prescription in a timely manner.

If Medicare finds out that the patient is receiving CGM supplies through both Medicare and the VA Medicare my come back and ask what the med nec is of the supplies twice a month. Just because the member pays for Medicare doesn't mean that receiving twice as many CGM supplies than they need per month and the overarching criteria for coverage of a service Medical Necessity. Regardless of the fact that the patient may have a copay, deductible or coinsurance for the supplies received through the Medicare program, the services still must be medically necessary.

The patient has told our staff that he will no longer be getting supplies from us and just going through the VA.

It sounds like the issue has resolved itself if the patient is no longer receive the supplies through their Medicare benefits, but if Medicare finds out about the months where supplies were received from both programs, they may go back to the patient to reimburse Medicare for the excessive CGM supplies that don't sound like they were medically necessary.

 

[xXxPARAGONxXx]

Hello!
I've recently been made aware of an issue, where a patient has been getting CGM supplies from Medicare, but also using VA benefits to get the same supplies. Basically doubling up on the supplies. My understanding is that a patient who has Medicare and VA benefits can choose between Medicare and VA benefits for a given service. However, this case sounds as if the patient was using both to get double the supplies. This sounded like a potential issue and I was just wondering if any of you have dealt with this before and what are the appropriate steps to take? The patient has told our staff that he will no longer be getting supplies from us and just going through the VA.
Thank you very much for any input on this! I appreciate it!

Hey @JillMedicalBiller, my original answer to your question was wrong. My apology.

Contrary to what I stated, the veteran should not be receiving his CGM supplies through Medicare if he is also receiving CGM supplies through the VA.

See the following from:

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/items-and-services-not-covered-under-medicare-booklet-icn906765.pdf

On p. 3 of 19:

Items & Services Not Covered Under Medicare
We don’t cover these items and services categories:
● Medically unreasonable and unnecessary services and supplies
● Non-covered items and services
● Services and supplies denied as bundled or included in another service’s basic allowance
● Items and services paid by other organizations or provided without charge

In addition, p. 17 of 19,

Items & Services Authorized or Paid by a Government Entity
We normally don’t pay for these items and services authorized or paid for by a federal, state, or local government entity:
● Those provided by a government or non-government provider or other individual at public expense authorized by a federal agency, like the Veterans Administration (VA).
● Those provided by a federal provider or agency. We may pay federal hospitals, like other non-participating hospitals, for emergency inpatient and outpatient hospital services.
● Those a federal, state, or local government entity directly or indirectly pays for or provides without expecting payment from any source and without regard to the individual’s ability to pay.
● Those that a non-government provider or supplier provides and either of these apply:
● A government program other than Medicare pays the charges.
● The provider or supplier intends to get payment from another government program (unless the payment by the other program is limited to Medicare deductible and coinsurance).

 

[JillMedicalBiller]

If Medicare finds out that the patient is receiving CGM supplies through both Medicare and the VA Medicare my come back and ask what the med nec is of the supplies twice a month. Just because the member pays for Medicare doesn't mean that receiving twice as many CGM supplies than they need per month and the overarching criteria for coverage of a service Medical Necessity. Regardless of the fact that the patient may have a copay, deductible or coinsurance for the supplies received through the Medicare program, the services still must be medically necessary.

It sounds like the issue has resolved itself if the patient is no longer receive the supplies through their Medicare benefits, but if Medicare finds out about the months where supplies were received from both programs, they may go back to the patient to reimburse Medicare for the excessive CGM supplies that don't sound like they were medically necessary.

Thank you for your input on this! I really appreciate it!

 

[JillMedicalBiller]

Hey @JillMedicalBiller, my original answer to your question was wrong. My apology.

Contrary to what I stated, the veteran should not be receiving his CGM supplies through Medicare if he is also receiving CGM supplies through the VA.

See the following from:

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/items-and-services-not-covered-under-medicare-booklet-icn906765.pdf

On p. 3 of 19:

Items & Services Not Covered Under Medicare
We don’t cover these items and services categories:
● Medically unreasonable and unnecessary services and supplies
● Non-covered items and services
● Services and supplies denied as bundled or included in another service’s basic allowance
● Items and services paid by other organizations or provided without charge

In addition, p. 17 of 19,

Items & Services Authorized or Paid by a Government Entity
We normally don’t pay for these items and services authorized or paid for by a federal, state, or local government entity:
● Those provided by a government or non-government provider or other individual at public expense authorized by a federal agency, like the Veterans Administration (VA).
● Those provided by a federal provider or agency. We may pay federal hospitals, like other non-participating hospitals, for emergency inpatient and outpatient hospital services.
● Those a federal, state, or local government entity directly or indirectly pays for or provides without expecting payment from any source and without regard to the individual’s ability to pay.
● Those that a non-government provider or supplier provides and either of these apply:
● A government program other than Medicare pays the charges.
● The provider or supplier intends to get payment from another government program (unless the payment by the other program is limited to Medicare deductible and coinsurance).

This was so helpful! Thank you!!