Avery--Medicare, money: ABN'S/INSURANCE

[Guest guest]

Hi Avery and all, Maybe you know the answer to this question, or maybe

someone else does. My understanding is that we cannot bill the

patient beyond what their insurance pays plus the co-pay. Is that

accurate? If so, I was wondering if we could use a form like the ABN

that you mentioned to get paid beyond what their insurance pays.

Anyone know? I find it frustrating to be paid 2/3 of what I charge

when I am treating many different issues beyond the elbow pain I'm

billing for.

 

How do others deal with this, and am I correct in thinking that we

cannot bill beyond the co-pay?

 

Thanks,

 

Laura

 

 

Chinese Medicine , " Dr. Avery L.

Jenkins " <ajenkins@c...> wrote:

>

> -

> <acudoc11@a...>

> <Chinese Medicine >

> Monday, November 22, 2004 10:17 PM

> Re: Medicare, money..

>

>

> >

> > When one compares their treatment to a Chiropractic adjustment or

as an

> > Acupuncturist

> > technician then I guess that person will get the bottom of the

barrell for

> > reimbursement.

> >

> > If one acts like a primary care provider and bills accordingly

they won't

> > wind up with $20.

> >

>

> Huh??

>

> What Medicare pays for services has little to nothing to do with

what you

> bill for them. Fees are established primarily by bureacratic fiat and

> approved Congressionally. If you you are a participating physician,

you have

> the extremely negligible advantage of having Medicare automatically

forward

> the unpaid portion of your bill to the patient's secondary insurance

(if

> any), for potential payment of the balance. The downside of that is

that as

> a par provider, you cannot balance bill the patient for the unpaid

portion

> of covered services.

>

> You may, however, bill the patient your standard fee for any

non-covered

> service, but only so long as you had the patient sign an ABN (Advance

> Beneficiary Notification), which states the service to be rendered,

the fee,

> and the reason you expect Medicare to reject the bill. The ABN must

be in a

> form approved by Medicare, which is readily downloaded off the net.

>

> As a non-participating provider, you can bill Medicare and then have

the

> advantage of being able to balance bill the patient for covered

services.

>

> You should also know that Medicare will soon be requiring all bills

to be

> submitted electronically. This places a huge burden on you to ensure

that

> your software can submit the bill (via a Medicare-approved

clearinghouse) in

> the proper format and that your entire office management system

meets HIPAA

> requirements.

>

> You should also be aware that Medicare, like other insurers, is

likely to

> highly restrict the diagnoses for which acupuncture treatment will be

> covered, and be prepared for a 3-6 month wait (minimum) for payment. In

> fact, I have many bills which have gone unpaid for as long as a year.

>

>

>

> Avery L. Jenkins, DC, DACBN, FIAMA

[Guest guest]

Laura,

 

It depends on the plan. In the HMO plans, if I am a participating provider,

I am prohibited by my contract with the HMO from balance-billing the patient

for the difference between what the HMO pays me + patient co-pay, and what

my standard fee is. Because of this, I only participate in 2 HMOs.

 

However, if I am not a participating provider, it often works out that there

is a deductible; until the deductible is met, the patient pays the standard

fee, after which the insurance company pays me a percentage of my standard

fee (usually 50-80%) and the patient pays me the outstanding balance.

 

The ABN form is only a Medicare requirement, Medicare plays by its own

rules; however, I or my staff always discuss the insurance situation with

the patient up front, so nobody gets any nasty surprises.

 

In personal injury cases, I bill my standard fees, for which the patient is

fully responsible. If there is insurance coverage, I will bill the auto

insurance; if they are represented by attorney, I have the patient sign a

lien, which states that I will be fully paid out of the patient's

settlement. While good money, PI cases usually take 2-6 years to resolve;

paperwork problems increase, in that the attorney always wants copies of the

clinical notes and usually a report. The attorney may also seek to cut your

fees at the last minute if the settlement comes out to less than expected.

 

The insurance companies will also seek to cut your fees in out-of-network

and PI cases as well, stating that they are responsible only for UCR (Usual,

Customary and Reasonable) charges, which somehow are always less than what I

bill.

 

It looks like the wave of the future is going to be plans with high

deductibles -- $1,000, $2,000, or $5,000 -- after which insurance kicks in.

In short, disaster insurance. Which is great for those of us in alternative

health, because on a level playing field, I can treat many conditions at

much less cost to the patient than western medicine.

 

My approach to insurance companies highly adversarial. I regard them all as

Spawn of Satan.

 

Avery L. Jenkins, DC, DACBN, FIAMA

 

-

" heylaurag " <heylaurag

<Chinese Medicine >

Tuesday, November 23, 2004 7:13 PM

Re: Avery--Medicare, money: ABN'S/INSURANCE

 

 

>

>

>

> Hi Avery and all, Maybe you know the answer to this question, or maybe

> someone else does. My understanding is that we cannot bill the

> patient beyond what their insurance pays plus the co-pay. Is that

> accurate? If so, I was wondering if we could use a form like the ABN

> that you mentioned to get paid beyond what their insurance pays.

> Anyone know? I find it frustrating to be paid 2/3 of what I charge

> when I am treating many different issues beyond the elbow pain I'm

> billing for.

>

> How do others deal with this, and am I correct in thinking that we

> cannot bill beyond the co-pay?

>

> Thanks,

>

> Laura

>

>

> Chinese Medicine , " Dr. Avery L.

> Jenkins " <ajenkins@c...> wrote:

>>

>> -

>> <acudoc11@a...>

>> <Chinese Medicine >

>> Monday, November 22, 2004 10:17 PM

>> Re: Medicare, money..

>>

>>

>> >

>> > When one compares their treatment to a Chiropractic adjustment or

> as an

>> > Acupuncturist

>> > technician then I guess that person will get the bottom of the

> barrell for

>> > reimbursement.

>> >

>> > If one acts like a primary care provider and bills accordingly

> they won't

>> > wind up with $20.

>> >

>>

>> Huh??

>>

>> What Medicare pays for services has little to nothing to do with

> what you

>> bill for them. Fees are established primarily by bureacratic fiat and

>> approved Congressionally. If you you are a participating physician,

> you have

>> the extremely negligible advantage of having Medicare automatically

> forward

>> the unpaid portion of your bill to the patient's secondary insurance

> (if

>> any), for potential payment of the balance. The downside of that is

> that as

>> a par provider, you cannot balance bill the patient for the unpaid

> portion

>> of covered services.

>>

>> You may, however, bill the patient your standard fee for any

> non-covered

>> service, but only so long as you had the patient sign an ABN (Advance

>> Beneficiary Notification), which states the service to be rendered,

> the fee,

>> and the reason you expect Medicare to reject the bill. The ABN must

> be in a

>> form approved by Medicare, which is readily downloaded off the net.

>>

>> As a non-participating provider, you can bill Medicare and then have

> the

>> advantage of being able to balance bill the patient for covered

> services.

>>

>> You should also know that Medicare will soon be requiring all bills

> to be

>> submitted electronically. This places a huge burden on you to ensure

> that

>> your software can submit the bill (via a Medicare-approved

> clearinghouse) in

>> the proper format and that your entire office management system

> meets HIPAA

>> requirements.

>>

>> You should also be aware that Medicare, like other insurers, is

> likely to

>> highly restrict the diagnoses for which acupuncture treatment will be

>> covered, and be prepared for a 3-6 month wait (minimum) for payment. In

>> fact, I have many bills which have gone unpaid for as long as a year.

>>

>>

>>

>> Avery L. Jenkins, DC, DACBN, FIAMA

[Guest guest]

Laura wrote: " My understanding is that we cannot bill the

patient beyond what their insurance pays plus the co-pay. Is that

accurate? "

 

That is only the case for managed care or similar insurance plans in which the

provider of service has signed a contract agreeing to charge only for the

contracted rate. On " fee for service " (indemnity) type of insurance, you can

charge the additional to get your payment up to your regular (customary) rates.

You should inform your patient of this beforehand by having this posted or

having them sign something explaining your billing practices. Matt

-

heylaurag

Chinese Medicine

Tuesday, November 23, 2004 4:13 PM

Re: Avery--Medicare, money: ABN'S/INSURANCE

 

 

 

 

Hi Avery and all, Maybe you know the answer to this question, or maybe

someone else does. My understanding is that we cannot bill the

patient beyond what their insurance pays plus the co-pay. Is that

accurate? If so, I was wondering if we could use a form like the ABN

that you mentioned to get paid beyond what their insurance pays.

Anyone know? I find it frustrating to be paid 2/3 of what I charge

when I am treating many different issues beyond the elbow pain I'm

billing for.

 

How do others deal with this, and am I correct in thinking that we

cannot bill beyond the co-pay?

 

Thanks,

 

Laura

 

 

Chinese Medicine , " Dr. Avery L.

Jenkins " <ajenkins@c...> wrote:

>

> -

> <acudoc11@a...>

> <Chinese Medicine >

> Monday, November 22, 2004 10:17 PM

> Re: Medicare, money..

>

>

> >

> > When one compares their treatment to a Chiropractic adjustment or

as an

> > Acupuncturist

> > technician then I guess that person will get the bottom of the

barrell for

> > reimbursement.

> >

> > If one acts like a primary care provider and bills accordingly

they won't

> > wind up with $20.

> >

>

> Huh??

>

> What Medicare pays for services has little to nothing to do with

what you

> bill for them. Fees are established primarily by bureacratic fiat and

> approved Congressionally. If you you are a participating physician,

you have

> the extremely negligible advantage of having Medicare automatically

forward

> the unpaid portion of your bill to the patient's secondary insurance

(if

> any), for potential payment of the balance. The downside of that is

that as

> a par provider, you cannot balance bill the patient for the unpaid

portion

> of covered services.

>

> You may, however, bill the patient your standard fee for any

non-covered

> service, but only so long as you had the patient sign an ABN (Advance

> Beneficiary Notification), which states the service to be rendered,

the fee,

> and the reason you expect Medicare to reject the bill. The ABN must

be in a

> form approved by Medicare, which is readily downloaded off the net.

>

> As a non-participating provider, you can bill Medicare and then have

the

> advantage of being able to balance bill the patient for covered

services.

>

> You should also know that Medicare will soon be requiring all bills

to be

> submitted electronically. This places a huge burden on you to ensure

that

> your software can submit the bill (via a Medicare-approved

clearinghouse) in

> the proper format and that your entire office management system

meets HIPAA

> requirements.

>

> You should also be aware that Medicare, like other insurers, is

likely to

> highly restrict the diagnoses for which acupuncture treatment will be

> covered, and be prepared for a 3-6 month wait (minimum) for payment. In

> fact, I have many bills which have gone unpaid for as long as a year.

>

>

>

> Avery L. Jenkins, DC, DACBN, FIAMA

 

 

 

 

 

 

 

 

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