Wiki Outpatient Surgery, MR Part A only, BCBS Secondary

[kblaisdell]

Hi everyone, hoping to get a little bit of help with this. I am working on cleaning up some old accounts at a new position with an OBGYN office. Our provider also does surgery and last year, performed an outpatient surgery for a patient who has Medicare Part A and BCBS Federal Secondary through her spouse.

BCBS will only pay as secondary to MR, and since it was an outpatient procedure, MR Part A won't cover any part of the surgery. The surgery was a major procedure and we are sitting at almost $15k in AR just on this one account.

Here's my question, should we appeal to BCBS to pay as primary as MR Part A does not cover outpatient surgery? Of the almost $15k billed, BCBS has only paid $1800 on the claim.

Thank you anyone for your help & advice!

 

[trarut]

Good luck if you try. There's a chance it could be a COB issue if the patient is still working and chose to not enroll in Part B. Most payers, when they are secondary to Medicare, are not going to pay at the primary rate because the patient chooses to not enroll in Part B and they spell it out in the policy language. We've had a few patients who opted out of Part B to avoid the premium, assuming their secondary would pay. Turned out their secondary policies clearly stated the plan would only cover the secondary liability and ultimately left the patient responsible for the 80% Part B would have covered.

 

[kblaisdell]

Thank you so much for your response. I wanted to make sure I understood it in my brain. The secondary is through her spouse and she is retired, however it is still secondary to her Part A. Thanks again.

 

[sls314]

Thank you so much for your response. I wanted to make sure I understood it in my brain. The secondary is through her spouse and she is retired, however it is still secondary to her Part A. Thanks again.

Is her spouse retired or still currently working?

I see you said she is retired. If her spouse is also retired, she may have penalties for not taking Part B.

 

[kblaisdell]

Is her spouse retired or still currently working?

I see you said she is retired. If her spouse is also retired, she may have penalties for not taking Part B.

I believe spouse is also retired, but has a BCBS Federal plan as part of his retirement package. I will have to do some more looking into this to find out! Thank you for your time!

 

[sls314]

I believe spouse is also retired, but has a BCBS Federal plan as part of his retirement package. I will have to do some more looking into this to find out! Thank you for your time!

She should have enrolled in Part B when her spouse retired. The FEP would have given up to $800 towards the Part B premiums. See more here: https://www.fepblue.org/our-plans/medicare

If she didn't take Part B, then her claims will still be processed as though she had Part B primary. She's responsible for what Medicare would have paid, and FEP will only pay what they would have paid secondary to Medicare. This is very common with retirement plans.

Unfortunately, if it has been more than 8 months since her spouse retired, she'd also be outside of the special enrollment window and would have a late enrollment penalty for the rest of her life.

She'd pay an extra 10% Part B premium for each year that she could have signed up for Part B but didn't. The longer it has been since her spouse retired, the bigger her penalty will be: https://www.medicare.gov/basics/costs/medicare-costs/avoid-penalties

Hopefully it has been less than 8 months since her spouse retired.