Common Concerns

 

 

 

 

Medicare

 

 

MEDICARE, WHAT IS IT?

 

Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, including those who have disabilities and those who have permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig’s disease). The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.

Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.

The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program.  However you apply for Medicare from Social Security.  They can give you general information about the Medicare program.

There are several web sites that are very informative and deal with your health care benefits under Medicare.  They include excellent links with information used in this introduction to Medicare

http://www.medicare.gov

http://www.cms.hhs.gov/home/medicare.asp

http://www.medicarerights.org

http://www.kff.org/medicare  

 

Overview:

 

Medicare has four parts

 

  • Hospital insurance (Part A) that helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.

  • Medical insurance (Part B) that helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.

  • Medicare Advantage (Part C) formerly known as Medicare + Choice plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.

  • Prescription drug coverage (Part D) that helps pay for medications doctors prescribe for treatment.

 

Beneficiary Cost Sharing and Out of Pocket Spending:

 

Medicare has relatively high cost-sharing requirements and covers less than half (45%) of beneficiaries’ total costs. Medicare premiums and cost-sharing requirements are indexed to rise annually; the monthly Part B premium has nearly doubled between 2000 and 2006.

In 2006, the Parts A, B, and D (standard) deductibles are $952, $124, and $250, respectively.

 

Unlike most employer-sponsored plans, Medicare has no cap on out-of-pocket spending.

 

The Role of Private Plans in Medicare:

 

Private plans are playing a larger role in Medicare through a revitalization of the Medicare managed care program, now known as Medicare Advantage, as well as through the new Part D drug benefit.

 

Medicare Advantage. Medicare HMOs have been an option under Medicare since the 1970s, although the majority of beneficiaries have remained in the traditional fee-for-service program.. In 2006, virtually all beneficiaries have a choice of one or more Medicare Advantage plans, with enrollment now at 16% of the total Medicare population.

 

Medicare pays HMOs and other plans to provide all Medicare-covered benefits).

 

Medicare Prescription Drug Plans. Beneficiaries can obtain the new Medicare drug benefit through private stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs). Medicare pays plans to provide the standard drug benefit, or one that is actuarially equivalent.

 

Additional Sources of Coverage:

 

In addition to Medicare, most beneficiaries have some form of supplemental coverage.

 

Employer-sponsored plans:

Employers are a key source of supplemental coverage, assisting about 11 million retirees on Medicare. However, retiree health benefits are on the decline; only 33% of large firms offered retiree benefits in 2005, down from 66% in 1988). An additional 2.6 million Medicare beneficiaries are active workers (or spouses) for whom employer plans are the primary source of coverage.

 

Medicaid:

More than 7 million low-income beneficiaries are dually eligible for Medicare and Medicaid. Most qualify for full Medicaid benefits, including long-term care and dental, and get help with Medicare’s premiums and cost-sharing requirements. Some do not qualify for full Medicaid benefits, but get help with Medicare premiums and some cost-sharing requirements under the Medicare Savings Programs, administered under Medicaid.

 

Medigap and other coverage:

Many beneficiaries purchase private supplemental policies, known as Medigap. 3 million beneficiaries receive supplemental assistance through the Veterans Administration or some other government program, according to HHS.

 

problems with prothesis reimbursement

In trying to update this problem, I put together some of the explanations and published this in our list 6/2/15... but this actually started in October 2010....

 

Medicare Changes….What does it all mean?
Meaghan Benjamin, Atos
(Taken from VoicePoints Whispers on the Web - Dec 2010)

This is an overview of what the most recent Medicare changes regarding L8509 include. It is being presented in a Q & A format based on the most common questions I have received from the field. I want to stress the importance of consulting the financial/billing people for your institution to determine all the nuances of billing. This overview is meant to answer general questions and help each clinician best determine how they need to proceed in order to meet the new guidelines. This change went into effect on Oct.1st 2010:

Why can't any DME companies such as ATOS or Apria bill for the indwelling style prosthesis any longer?

Atos Medical is considered a Durable Medical Equipment company. Medicare has taken indwelling style prostheses away from the DME MAC which is the division of Medicare that DME companies are able to submit claims to for reimbursement. Indwelling style prostheses have been moved into A/B MAC which is the division that hospitals/facilities submit claims to for reimbursement. In order for a reimbursement to be processed, the facility must purchase and bill for the prosthesis.

What is DME? Durable Medical Equipment.

In order for something to be considered DME, it generally falls under the following guidelines: (1) Can be used again (2) Can be used in the home (3) Is not useful in the absence of illness or injury (4) Is either rented or purchased (5) Is single patient use

As a facility, we are not a licensed DME provider and are unable to bill for durable medical equipment. Does this mean we can't bill for the indwelling style prosthesis?

No, you should be able to bill for the indwelling style prosthesis (L8509) as it is no longer considered a DME item and as such can only be billed by non DME facilities such as the hospital or doctor's office. As a result, your facility can now bill for indwelling style prostheses and get reimbursed even if they are not a licensed DME provider.

If we are not a licensed DME provider, can we bill Medicare for other items such as HMES or Freehands valve?

No, you can not as HMES fall under DME and in order to bill Medicare for DME, you must have licensed DME provider status.

What about non-indwelling style prostheses (L8507). How are those billed?

Non Indwelling style prostheses (L8507) are still considered to be DME as they are patient changeable. As a result, in order to bill for reimbursement, these would fall under the same category as HMEs or Freehands valves and can only be billed to Medicare by a licensed DME provider. As a result, the DME companies can continue to submit claims on behalf of the patients for these items.

How does Medicare reimbursement work for DME items?

To give an example, Indwelling style prostheses all use the same HCPC code regardless of brand. Medicare has a fee schedule that is set based on Region and is referred to as the allowable rate. Medicare reimburses 80% of their allowable rate. If the allowable rate in your region is 115.00, Medicare will reimburse 92.00 for an indwelling prosthesis. The patient and/or secondary insurance is typically responsible for the rest. The way most facilities submit billing is to include the CPT (procedural code) as well as the HCPC code for the device used during the procedure.

How does it work with private Insurance?

Currently, DME providers can still submit claims on behalf of patients for all items including L8509 indwelling style voice prostheses.

If my facility is not a licensed DME provider, can I still bill the private insurances for all items related to laryngectomy care?

This is an excellent question for your billing people. Technically the answer is yes. Remember, the definition of DME is the same for both Medicare and Private so you can only bill each patient one time for each item used with that patient. All billable items must be new and single patient use. To determine your reimbursement, you should work directly with your financial/billing people to determine the contract you have with individual private insurance companies which will determine how your facility bills and is reimbursed from private insurance companies.

Our facility doesn’t stock indwelling style prostheses. Can a patient call one of the Vendors and purchase an indwelling style prosthesis directly?

Yes, as long as they have the appropriate prescription on file. If the patient is Medicare, the patient needs to agree that no claims will be filed for reimbursement (ABN form) and as a result, accept responsibility for payment. If the patient has private insurance, the vendor can file their claim as has been customary.

According to CMS, what HCPC codes regarding Postlaryngectomy care can be billed by a hospital/facility that are a non-licensed DME provider?

L8509 (indwelling style prostheses)

According to CMS, What HCPC codes regarding post laryngectomy care can ONLY be billed by a licensed DME provider?

A7501 Free Hands Starter Kit
A7502 Free Hands Membranes
A7503 Titanium Cap
A7507 HME Cassettes
A7508 Baseplates
A7520 Larytube
A7523 Shower Aid
A7524 Larybutton/Barton Button
A4456 Remove
A4364 Silicone Glue
A7526 Laryclip/tube holder
A4456 Provox cleaning towel
A9270 Free Hands cleaning and storage box
E1700 Therabite System
E1701 Therabite Bite pads
E1702 Therabite ROM scales
L8500 Electrolarynx
L8505 Trutone Hands Free
A5120 (AU) Skin Tac
L8507 Non Indwelling Style Prosthesis
L8510 Personal Amplifier (i.e boomvox, chattervox, sonivox etc)
L8511 plug
L8512 Gel caps (quantities of 10)
L8513 Brush
L8514 Dilator
L8515 Gel Cap Insertion System
L8499 Kapigel Spacer

Basically this means that all products and accessories associated with laryngectomy supplies (with the exception of L8509) can only be billed to medicare for reimbursement if your facility is a licensed DME provider.

=============================================
MORE….

In the WW Forum, we have a notice posted about InHealth and Edgepark:
Lary Products & Suppliers - Edgepark Carries Blom-Singer® Products

From: Kevin Madden 11/5/12

InHealth has partnered with Edgepark to provide you with the best possible
care Good news! Now you can purchase your Blom-Singer® products through
Edgepark. Edgepark carries Blom-Singer® products, including
§ Voice prostheses and accessories
§ HMEs
§ Housings and supplies
§ Laryngectomy tubes
Edgepark offers the most extensive insurance coverage of any full-line,
mail-order medical supplier. Edgepark can work with you to find out if your
insurance covers your supply needs. Call or visit Edgepark online
Web: www.edgepark.com
Phone: 1-800-321-0591
(There is an attachment, but we cannot send attachments to this list.)

In our Forum were letters from both ATOS and InHealth explaining what was happening at the time it happened.
=========================================================

In our list archives, a great letter from Carla DeLassus Gress, ScD, CCC-SLP explained to one of our members what her choices were and she lays it our very plainly. You should be able to bring this up in our archives… Password is sent to you EVERY weekend in Jeff’s report..


HIGHLIGHTS:
There are a few options: Switch to a patient-changeable device, if that is appropriate for you. Even if you can't change the prosthesis yourself and need the clinician to do it, you can use a pt-changeable device as though it was an "indwelling-style" and have the clinician change it as they have been doing.

Another option is to find a clinician that stocks the clincian-changeable prosthesis that you like. If you are in a large metro area, you might have more success locating a facility which will provide the device to you and bill Medicare.

The last (as in last resort) option would be to pay out of pocket if the pt has the financial resources to do so. Personally I think this is a disgrace, since most of our Medicare pts have paid their dues and should be able to get reimbursed for a medical device that helps to restore speech for a medical problem, and not have to jump through 356 hoops to get it!

==========================================================

My personal note:

I am using the B-S change it yourself prosthesis. I order them 2 at a time, pay. They file with Medicare and the money is returned to me by Medicare and AARP -Plan F and I think covers all or most of it. I do not take them to an SLP to change. Mine is the old fashioned way but it works! I think the low pressure self-changing one still sell for about $70 each.

Pat Sanders
lary 1995

 


Advice from our Members

June 2011

This person, who asked for her Mom, is dealing with MediCare (HMO)with Secure Horizons as a primary. But She also has MediCal (Medicaid) as a second/backup (whatever that means). She is getting ready to have chemo and the drug is only 80% covered by Secure Horizons (MediCare).

The chemo provider should be told of her MediCal coverage on the
initial visit and should bill them as secondary after the HMO claim is
processed.

Secure Horizons Medicare Advantage health insurance plans are sold by
United Healthcare Insurance company . They offer, among other plans,
a Medicare advantage HMO. Medicare Advantage plans are private health
insurance plans that replace original Medicare for patients who choose
these plans. Mom has to be sure she follows the HMO rules on
referrals and stays in the HMO network of providers to get the most
benefit from her plan. She should have a benefit booklet which
explains all of this and a primary care doctor to oversee her care.
Secure Horizons offers more than one HMO plan so you need to
understand which one she is in . See her booklet and this website
www.securehorizons.com/options/medicareadvantage.html

Her Secure Horizons insurance is her primary insurance. The primary
insurance will pay first and the rules of the primary insurance have
to be followed to get them to pay and usually to get any coverage from
the secondary insurance.
Secondary insurance pays after the primary and may pick up any
balances or cost shares remaining. It is important that each medical
provider ( doctor, hospital, clinic, etc) know that she has a
secondary and bills to the secondary after the primary has paid. You
want to avoid having to bill the secondary yourself as the
documentation needed can be difficult to manage. Secondary private
insurance would process a received medical claim to determine what
they would have paid had their insurance been primary, compare that
amount to the balance remaining on the provider’s bill and pay the
lesser of the two amounts . Medi-Cal should work much the same way.

MEDI-Cal is California’s Medicaid program and will function as her
secondary insurance. As a publicly funded program, the claim
processing rules may be a little different so you need to check with
them to understand the specifics. It is likely that the chemo billers
are very familiar with all of this. See for information on MEDI-Cal.


http://www.dhcs.ca.gov/services/medi-cal/Pages/default.aspx

Make sure that each medical office that she deals with understands
her insurance and has current copies of her insurance cards. Many
issues can be avoided if the medical bills are submitted correctly the
first time.

Nick Fuhs
Class of 94
Former health insurance analyst

 


 

APPEALS

My suggestion is to appeal within the 30-day period. Make an appeal even if you don't think you have solid grounds. If the MedAdvantage plan denies your appeal, you get a second chance to appeal before a "independent" Medicare-appointed arbitrator. Perhaps all you need to say is that the procedure was pre-approved and clearly the MedAdvantage plan had made a
clerical error in giving the denial.

I am constantly getting claims denied. So far, I've been able to reverse the denial on appeal in 100% of the cases. Most of the time, the denial is overturned on the first appeal; but once Ihad to make a second appeal the Medicare-appointed arbitrator.

Be sure to send you appeal by certified mail, and get the signed receipt of the appeal. Without proof that you actually sent the appeal ina timely manner, you have no hope.

R Walloch

 


 

From the Kaiser Family Foundation, February 2007

Information specific to Coverage of Supplies:

There have been many questions about Medicare coverage of Durable Medical Equipment (DME).  It is important to understand that our coverage and co-pays are affected by the provider we deal with.  Understanding this will help us understand the differences in coverage.  It is not that Medicare is different from state to state, the status of our provider with Medicare is what may be different.   Reimbursement from Medicare is standard based on the following criteria: 

Please pay particular attention to the following if you are covered by Medicare. 

 

What is the difference between "participating" and "non-participating" suppliers of durable medical equipment (DME)?

 

There are three types of Durable Medical Equipment (DME) suppliers. The one you choose affects how much your costs will be.

 

  • Suppliers who are enrolled and "participating" in Medicare must bill Medicare and accept assignment (the Medicare-approved amount) as payment in full. You can only be billed 20 percent of that amount (plus any unmet portion of your Part B deductible).
  • Suppliers who are enrolled but "not participating" in Medicare are not required to accept assignment. They are allowed to charge you their standard rate and can ask for payment up front. Medicare will then reimburse you for 80 percent of its approved amount, and you pay the balance.
  • Suppliers who are not enrolled in Medicare are not required to bill Medicare. You may have to submit the claim to Medicare yourself. These suppliers are allowed to charge you their standard rate and can ask for payment up front. Medicare may then reimburse you for 80 percent of its approved amount, and you pay the balance.

 

Note: You must go to an enrolled supplier to get coverage for medications, diabetes supplies and capped rental items.

 

Why is it better to find a durable medical equipment supplier who takes Medicare assignment?

 

Unlike doctors, if a DME supplier accepts Medicare but does not take Medicare’s assignment, it can charge you any amount over Medicare’s allowed amount. That means you will be responsible for the 20 percent coinsurance plus whatever else the supplier wants to charge.

 

Visit www.medicare.gov or call 1-800-MEDICARE for a list of DME suppliers who accept assignment.

 

 

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