Wiki Medicare claim denial ?

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RebeccaB

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One of our physicians saw pt in the hospital (inpt consult) Primary insurance Anthem paid on the claim, secondary ins Medicare denied because they no longer pay consults-How do I get the claim processed through Medicare ??

Thanks for any thoughts, ideas

Rebecca
 
The medicare manual addresses this issue. The preferred way is to bill to the primary the same way you would bill it to Medicare. Some will tell you to change the code but then the medicare claim does not match and some will not pay for hat reason. Or bill it to the primary as a consult and write off the balance.
 
CMS MLN Matters Article number SE1010 pages 5 and 6 answer this question. According to CMS you can either bill the primary insurance the way you would bill Medicare (which may not be paid if you bill 9922x and you are not the admitting provider) or you can bill a consult to the primary and then bill the appropriate code to Medicare with the primary payment amount. We've done this since 2010 without any problems getting paid by Medicare. The only thing we have to remember is to override the charge amount (if it's different) when changing the code for Medicare. The only time we've had a problem is when we've forgotten to change the charge amount to match the original bill. I've attached the link to the MLN Matters Article. http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/se1010.pdf
 
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