Medicare FAQ
1. Why am I billed for some of the medication I am given while receiving services at the hospital as an outpatient?
During the course of your outpatient treatment, you may be given medication that is considered self-administrable by Medicare. Self-administrable drugs are defined by Medicare as medications that the patient could, in another setting, take him or herself. The list of medications includes tablets, sprays, drops, inhalants and some common injectable drugs.
In order to remain compliant with Medicare regulations related to the billing of these drugs, medical providers are required to submit these self-administrable drugs as non-covered items on our billing to Medicare.
You will receive a bill from the hospital following payment of our claim by Medicare. In addition to any deductible and co-insurance due, this bill will reflect the charges for unpaid self-administrable drugs. Payment for non-covered items will be expected from you. With few exceptions, most secondary insurance carriers do not cover self-administrable drugs.
Please review your Medicare Beneficiary Handbook for information on coverage of medications dispensed on an outpatient basis. To obtain additional information on this subject, please contact the Medicare Beneficiary Help Line at (800) 522-8323.
2. What is the purpose of an Advanced Beneficiary Notice (ABN)?
Medicare has established guidelines to ensure that all tests or procedures performed on Medicare beneficiaries are medically necessary.
When your physician writes an order for a test, he or she includes the diagnosis or reason for the test on the order. After the test is completed, the hospital will bill Medicare for payment. Medicare requires that all claims submitted on behalf of a Medicare beneficiary include the type of test and the medical reason for the test. If the diagnosis does not meet Medicare’s established criteria for medical necessity, payment for the claim will be denied.
It is our responsibility, as the provider of care, to notify our patients prior to testing if the diagnosis supplied by the physician does not meet Medicare’s medical necessity guidelines. In these cases, the patient will be asked to sign an Advance Beneficiary Notice acknowledging that the patient is aware that Medicare may not pay the claim and accepts financial responsibility for payment.
3. If Medicare will not pay for a test, does that mean I do not need the test?
No. Your doctor bases decisions about testing on a wide range of factors including such things as your personal medical history, any medications you might be taking and generally accepted medical practices. Even if your doctor believes a test will provide useful information in order to give you the best care, it is possible that Medicare may not consider the test to be medically necessary for your diagnosis.
4. Why am I asked to complete a Medicare Secondary Payor Questionnaire?
Medicare requires that medical care providers obtain certain types of information from Medicare beneficiaries each time a test or procedure is performed.
Your responses to the questions are used by Medicare to ensure appropriate assignment of payment liability. In other words, Medicare should not be billed for charges that may be the responsibility of another payment source. For example, if you were seeking treatment for an automobile accident, any accident insurance would need to be billed prior to billing Medicare.
Some of the information collected on this questionnaire is maintained in your permanent Social Security record and each claim submitted on your behalf is matched to this record. We understand that answering these questions each time you are treated can be an inconvenience, however, it is extremely important that we adhere to Medicare requirements and that we submit the most accurate information available. We appreciate your assistance and understanding as we endeavor to comply with Medicare’s claim requirements.
5. How does Medicare cover outpatient services?
Effective 09/01/01, Littleton Regional Hospital was designated as a Critical Access Hospital (CAH). As a CAH, most outpatient services are paid by Medicare based on a percentage of the charges submitted by the hospital for your testing or treatment. Your co-payment is assessed at 20% of the submitted charges, except for certain charges, such as laboratory tests, for which there is no co-insurance due from you. (Prior to becoming a CAH, Littleton Regional Hospital was reimbursed under the Ambulatory Procedural Code (APC) claim processing method. Medicare assigned a flat payment amount to certain outpatient services and your co-payment was assessed at 20% of the assigned payment amount. For some services your co-payment could be higher under APCs than when co-payments are calculated at 20% of billed hospital charges.).
· We will continue to bill your secondary insurance for the balance after Medicare satisfies their portion of the claim.
· All Medicare requirements for medical necessity and MSPQ will remain in effect.
· Medicare has established a help line at (800) 522-8323 to assist you with any questions.
6. Is there some place that I can get additional information concerning my coverage by Medicare?
Yes. You can call 1-800-MEDICARE or visit www.medicare.gov to get help with your Medicare questions.
7. What is the difference between Medicare and Medicaid?
A: MEDICARE is an insurance program. Medical bills are paid from trust funds that those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Health Care Financing Administration, an agency of the federal government.
MEDICAID is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines.
|