medicare1

Medicare 1

The Voice of Courage
PUBLISHED TO ENLIGHTEN THE NEW LARYNGECTOMEES ABOUT THEIR FUTURE LIFE, SINCE MID 1972

By Dean Rosecrans P.O. Box 310 Nampa, Idaho 83653 1-800-237-3699 05/13/2004

Mandatory Filing | SNF & Inpatient Stays | HHAPPS | Hospice Election

| Mandatory Filing |

1.               For services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and nonassigned Part B claims for beneficiaries.
The claims filing requirement applies to all suppliers who provide covered services to Medicare beneficiaries.

Suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Supplier Program.

Suppliers may not charge the beneficiary for preparing and filing a Medicare claim. The beneficiary may also not be charged for the completion of a Certificate of Medical Necessity (CMN) form. The carrier will monitor supplier compliance with the Medicare claims filing requirement. Suppliers who do not submit Medicare claims for Medicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 for each violation.

If the supplier determines that the beneficiary has other insurance which may pay primary to Medicare, they may file a claim with the primary insurer on the beneficiary's behalf. However, suppliers are not required by law to submit claims to other payers. If the supplier receives a determination on the claim directly from the primary payer, they are responsible for submitting a claim to Medicare for secondary payment. If the beneficiary files a claim to the primary insurer, they may forward the primary payer information to the supplier to submit the Medicare Secondary Payer (MSP) claim. The supplier must submit the secondary claim to Medicare for the beneficiary in accordance with the mandatory claims filing requirements.

Supplier/Beneficiary Payment Arrangements - Suppliers who do not accept assignment may continue to request payment in full at the time that the service is provided if the claim for this service is unassigned. We encourage you to file the claims about the same time you request payment. This will reduce a potential financial hardship for the patient and reduce future inquiries you may receive regarding the status of the claim.

Non-Covered Medicare Services - Suppliers are not required to file claims on behalf of Medicare beneficiaries for non-covered benefits or for other health insurance benefits.

... to inform a Medicare beneficiary, before he or she receives specified items or services that otherwise might be paid for, that Medicare probably will not pay for them on that particular occasion. ... the beneficiary to make an informed consumer decision whether or not to receive the items or services for which he or she may have to pay out of pocket or through other insurance. In addition, ... allows the beneficiary to better participate in his/her own health care treatment decisions by making informed consumer decisions. If the physician or supplier expects payment for the items or services to be denied by Medicare, the physician or supplier must advise the beneficiary before items or services are furnished that in their opinion the beneficiary will be personally and fully responsible for payment. To be "personally and fully responsible for payment" means that the beneficiary will be liable to make payment "out-of-pocket," through other insurance coverage (e.g., employer group health plan coverage), or through Medicaid or other Federal or non-Federal payment source. The physician or supplier must issue notices each time, and as soon as, they make the assessment that Medicare payment probably or certainly will not be made. If a physician or supplier fails to provide a proper Advanced Beneficiary Notice in situations where one is required, you may find the physician or supplier to be liable under the provisions of LOL or RR, where such provisions apply, unless the physician or supplier can show that they did not know and could not reasonably have been expected to know that Medicare would deny payment. ... must state that the physician or supplier believes Medicare is likely (or certain) to deny payment for the particular item or service, and must give the physician's or supplier's reason(s) for their belief that Medicare is likely (or certain) to deny payment for the item or service.

Summary

Your supplier must file your claim. Your supplier must notify you if the supplies you wish to purchase may not be covered by medicare and the reason.

| SNF & Inpatient Stays |

1.                Section 4432(b) of the Balanced Budget Act (BBA) requires Consolidated Billing for the SNF. The CB requirement essentially confers on the SNF itself the Medicare billing responsibility for the entire package of care that its residents receive, except for a limited number of specifically excluded services.
For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs will no longer be able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to the Medicare carrier. Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. As a result, the outside provider of the service or supplies must look to the SNF, rather than to the beneficiary or the Medicare carrier, for payment.

The DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institution is not defined as a beneficiary’s home for DMEPOS. Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.

However, there is an exception to the general rule above. In accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the "from" date or anniversary date defined below.

For DME items where the supplier submits a monthly bill, the date of delivery ("from" date) on the first claim must be the "from" or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).

If a beneficiary using DME is at home on the "from" date or anniversary date, Medicare will make payment for the item for the entire month, even if the "from" date is the date of discharge from the institution.

If a beneficiary using DME is in a covered Part A stay for a full month, Medicare will not make payment for the item for that month.

When the "from" date on the DMEPOS claim falls within an inpatient stay and the beneficiary returns home within the same calendar month, the supplier must submit a new claim on the date of discharge from the institutional provider and the date of discharge will become the "from" (anniversary) date for all subsequent claims.

Summary

While in a Skilled Nursing Facility, you are covered by Medicare Part A until your maximum benefit is reached. While covered by Part A, you may not purchase any supplies under Part B. Laryngectomee filters, artificial larynx, batteries and repairs are all covered under Part B. When entering a Skilled Nursing Facility, make sure they have a supplier for your laryngectomee needs. They will be responsible for ordering and providing them during your stay.

During an in-patient hospital stay, you are also covered by Medicare Part A, and have no Part B benefits.

Mandatory Filing | SNF & Inpatient Stays | HHAPPS | Hospice Election

| HHAPPS |

1.                The Balanced Budget Act of 1997 requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, billing for all such items and services will be made to a single home health agency (HHA) overseeing that plan.

The law states that payment will be made to the primary HHA whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements existed with the primary agency, or "otherwise." Payment for all items is scheduled in the home health PPS episode payment that the primary HHA receives.

Types of services that are subject to the home health consolidated billing provision include:

Skilled nursing care;

Home health aide services;

Physical therapy;

Speech-language pathology;

Occupational therapy;

Medical social services;

Routine and non-routine medical supplies; (see following)

Non-Routine Medical Supplies (DMERCs)

When a beneficiary is in a 60-day episode, these items are included in the PPS episode payment. HHAs must bill for all supplies provided during the 60-day episode including those not related to the Plan of Care because of the consolidated billing requirements.
...
A4344    A4481    A5131   A6228    A6402
...
With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list which are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods.

Summary

During a Home Health episode, all your laryngectomee filter supplies must be ordered through the Home Health Agency. Artificial larynx, batteries and repairs are not included in a Home Health episode. Your home Health Agency must supply your filters. If your regular supplier agrees to sell to you, they are required to file a medicare claim. When they file the medicare claim, it will be denied because you are covered by a Home Health Agency. They will be forced by medicare to refund your money. For this reason, you must give your supplier information to your Home Health Agency, so they will be ready to provide your filters when you need them.

| Hospice Election |

M + C organizations may bill the Medicare carrier for non-hospice services provided to M + C enrollees who elect hospice benefits. These claims should be submitted with a GW (for services not related to the terminal condition) modifier as applicable. Carriers process these claims in accordance with regular claims processing rules.

Any covered Medicare services not related to the treatment of the terminal hospice condition, and which are furnished during a hospice election period, may be billed by the rendering provider to the Fiscal Intermediary (FI) or carrier for non-hospice Medicare payment. These services are coded with the GW modifier "service not related to the hospice patient’s terminal condition" when submitted to a carrier. Contractors process services coded with the GW modifier in the normal manner for coverage and payment determinations. If warranted, contractors may conduct prepayment development or post payment review to validate that services billed with the GW modifier are not related to the patient’s terminal condition.

Summary

When you take the Hospice Election for Medicare Part B benefits, your laryngectomee supplies may or may not be covered. It is best to have the Hospice purchase the supplies and bill accordingly.

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Medicare 1
The Voice of Courage PUBLISHED TO ENLIGHTEN THE NEW LARYNGECTOMEES ABOUT THEIR FUTURE LIFE, SINCE MID 1972 By Dean Rosecrans P.O. Box 310 Nampa, Idaho 83653 1-800-237-3699 05/13/2004
Mandatory Filing \| SNF & Inpatient Stays \| HHAPPS \| Hospice Election
\| Mandatory Filing \| 1. For services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and nonassigned Part B claims for beneficiaries. The claims filing requirement applies to all suppliers who provide covered services to Medicare beneficiaries. Suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Supplier Program. Suppliers may not charge the beneficiary for preparing and filing a Medicare claim. The beneficiary may also not be charged for the completion of a Certificate of Medical Necessity (CMN) form. The carrier will monitor supplier compliance with the Medicare claims filing requirement. Suppliers who do not submit Medicare claims for Medicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 for each violation. If the supplier determines that the beneficiary has other insurance which may pay primary to Medicare, they may file a claim with the primary insurer on the beneficiary's behalf. However, suppliers are not required by law to submit claims to other payers. If the supplier receives a determination on the claim directly from the primary payer, they are responsible for submitting a claim to Medicare for secondary payment. If the beneficiary files a claim to the primary insurer, they may forward the primary payer information to the supplier to submit the Medicare Secondary Payer (MSP) claim. The supplier must submit the secondary claim to Medicare for the beneficiary in accordance with the mandatory claims filing requirements. Supplier/Beneficiary Payment Arrangements - Suppliers who do not accept assignment may continue to request payment in full at the time that the service is provided if the claim for this service is unassigned. We encourage you to file the claims about the same time you request payment. This will reduce a potential financial hardship for the patient and reduce future inquiries you may receive regarding the status of the claim. Non-Covered Medicare Services - Suppliers are not required to file claims on behalf of Medicare beneficiaries for non-covered benefits or for other health insurance benefits. ... to inform a Medicare beneficiary, before he or she receives specified items or services that otherwise might be paid for, that Medicare probably will not pay for them on that particular occasion. ... the beneficiary to make an informed consumer decision whether or not to receive the items or services for which he or she may have to pay out of pocket or through other insurance. In addition, ... allows the beneficiary to better participate in his/her own health care treatment decisions by making informed consumer decisions. If the physician or supplier expects payment for the items or services to be denied by Medicare, the physician or supplier must advise the beneficiary before items or services are furnished that in their opinion the beneficiary will be personally and fully responsible for payment. To be "personally and fully responsible for payment" means that the beneficiary will be liable to make payment "out-of-pocket," through other insurance coverage (e.g., employer group health plan coverage), or through Medicaid or other Federal or non-Federal payment source. The physician or supplier must issue notices each time, and as soon as, they make the assessment that Medicare payment probably or certainly will not be made. If a physician or supplier fails to provide a proper Advanced Beneficiary Notice in situations where one is required, you may find the physician or supplier to be liable under the provisions of LOL or RR, where such provisions apply, unless the physician or supplier can show that they did not know and could not reasonably have been expected to know that Medicare would deny payment. ... must state that the physician or supplier believes Medicare is likely (or certain) to deny payment for the particular item or service, and must give the physician's or supplier's reason(s) for their belief that Medicare is likely (or certain) to deny payment for the item or service. Summary Your supplier must file your claim. Your supplier must notify you if the supplies you wish to purchase may not be covered by medicare and the reason.		\| SNF & Inpatient Stays \| 1. Section 4432(b) of the Balanced Budget Act (BBA) requires Consolidated Billing for the SNF. The CB requirement essentially confers on the SNF itself the Medicare billing responsibility for the entire package of care that its residents receive, except for a limited number of specifically excluded services. For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs will no longer be able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to the Medicare carrier. Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare. As a result, the outside provider of the service or supplies must look to the SNF, rather than to the beneficiary or the Medicare carrier, for payment. The DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institution is not defined as a beneficiary’s home for DMEPOS. Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay. However, there is an exception to the general rule above. In accordance with DMEPOS payment policy, Medicare will make a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the "from" date or anniversary date defined below. For DME items where the supplier submits a monthly bill, the date of delivery ("from" date) on the first claim must be the "from" or anniversary date on all subsequent claims for the item. For example, if the first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.). If a beneficiary using DME is at home on the "from" date or anniversary date, Medicare will make payment for the item for the entire month, even if the "from" date is the date of discharge from the institution. If a beneficiary using DME is in a covered Part A stay for a full month, Medicare will not make payment for the item for that month. When the "from" date on the DMEPOS claim falls within an inpatient stay and the beneficiary returns home within the same calendar month, the supplier must submit a new claim on the date of discharge from the institutional provider and the date of discharge will become the "from" (anniversary) date for all subsequent claims. Summary While in a Skilled Nursing Facility, you are covered by Medicare Part A until your maximum benefit is reached. While covered by Part A, you may not purchase any supplies under Part B. Laryngectomee filters, artificial larynx, batteries and repairs are all covered under Part B. When entering a Skilled Nursing Facility, make sure they have a supplier for your laryngectomee needs. They will be responsible for ordering and providing them during your stay. During an in-patient hospital stay, you are also covered by Medicare Part A, and have no Part B benefits.
Mandatory Filing \| SNF & Inpatient Stays \| HHAPPS \| Hospice Election
\| HHAPPS \| 1. The Balanced Budget Act of 1997 requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, billing for all such items and services will be made to a single home health agency (HHA) overseeing that plan. The law states that payment will be made to the primary HHA whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements existed with the primary agency, or "otherwise." Payment for all items is scheduled in the home health PPS episode payment that the primary HHA receives. Types of services that are subject to the home health consolidated billing provision include: Skilled nursing care; Home health aide services; Physical therapy; Speech-language pathology; Occupational therapy; Medical social services; Routine and non-routine medical supplies; (see following) Non-Routine Medical Supplies (DMERCs) When a beneficiary is in a 60-day episode, these items are included in the PPS episode payment. HHAs must bill for all supplies provided during the 60-day episode including those not related to the Plan of Care because of the consolidated billing requirements. ... A4344 A4481 A5131 A6228 A6402 ... With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list which are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Summary During a Home Health episode, all your laryngectomee filter supplies must be ordered through the Home Health Agency. Artificial larynx, batteries and repairs are not included in a Home Health episode. Your home Health Agency must supply your filters. If your regular supplier agrees to sell to you, they are required to file a medicare claim. When they file the medicare claim, it will be denied because you are covered by a Home Health Agency. They will be forced by medicare to refund your money. For this reason, you must give your supplier information to your Home Health Agency, so they will be ready to provide your filters when you need them.		\| Hospice Election \| M + C organizations may bill the Medicare carrier for non-hospice services provided to M + C enrollees who elect hospice benefits. These claims should be submitted with a GW (for services not related to the terminal condition) modifier as applicable. Carriers process these claims in accordance with regular claims processing rules. Any covered Medicare services not related to the treatment of the terminal hospice condition, and which are furnished during a hospice election period, may be billed by the rendering provider to the Fiscal Intermediary (FI) or carrier for non-hospice Medicare payment. These services are coded with the GW modifier "service not related to the hospice patient’s terminal condition" when submitted to a carrier. Contractors process services coded with the GW modifier in the normal manner for coverage and payment determinations. If warranted, contractors may conduct prepayment development or post payment review to validate that services billed with the GW modifier are not related to the patient’s terminal condition. Summary When you take the Hospice Election for Medicare Part B benefits, your laryngectomee supplies may or may not be covered. It is best to have the Hospice purchase the supplies and bill accordingly.