“We have a handful of patients who have traditional Medicare with a secondary we don't participate with. Is it ok to tell them we don't participate and bill them what Medicare says is patient responsibility? If asked, do we need to provide anything so they can file on their own? Each visit the amount Medicare doesn't pay is about $30. This is adding up. We use NextGen and in searching their Payer List these little secondary companies aren't listed."
When a patient is covered by Traditional Medicare, it should be made very clear so that the patient understands that Traditional Medicare only reimburses 80% of what the Medicare Part B allowed reimbursement amount is after the annual deductible is paid. That is the reason why most patients that are covered by Traditional Medicare also purchase a secondary, supplemental insurance policy (ie. Medigap) to cover the 20% that Traditional Medicare does not cover.
While physicians that participate with Traditional Medicare are reimbursed 80% of the allowed amount, not all physicians participate as providers with every secondary, supplemental insurance plan.
If the physician does not accept/participate with the patient’s secondary insurance plan, the patient needs to be made aware of this issue in advance of service. Here are the options:
1. The patient can elect to receive care from a provider that accepts the secondary, supplemental insurance.
2. The patient will receive an EOB (Explanation of Benefits) from Traditional Medicare advising them of the amount that Traditional Medicare allowed and reimbursed for the service(s) rendered. The patient is then responsible for the 20% that Medicare did not reimburse. It would be appropriate to send the patient a statement for the 20% that Traditional Medicare did not reimburse.
3. If the patient is unaware that they received an EOB in the mail, the physician can provide the patient with a copy of the EOB that the physician received. The patient is still responsible for the 20% that Traditional Medicare did not reimburse.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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