Category Archives: Pap smears

How to bill Medicare HMOs

I know that is a very ambitious title, but a few people here have been emailing me with questions on this topic. I figure, if a few of my readers are taking the time to email me, then there are far more of you out there with questions. The good news is, the answer is fairly simple.

The emails I have been receiving fall into three main categories.

1. How do I bill a pap smear to a Medicare Risk HMO?

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

3. When Medicare says a patient has an HMO, is Medicare secondary?

And here are your answers:

1.  How do I bill a pap smear to a Medicare Risk HMO?

As you might remember from my previous post, Everything you ever wanted to know about pap smears, each HMO has its own way of doing things. Some want the diagnosis V72.31, others want V76.2. Some want to follow Medicare rules, and some want to pay with the preventative code.  Some won’t pay anything at all, instead they capitate it. The best way to find out how your HMO will pay your provider’s claim is to get a copy of the provider’s contract.  

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

By and large, the Medicare Risk HMO plans want us to use the Medicare codes for the flu and pneumonia substances. For the flu, use the Q-codes for the substance and the G0008 for the administration. For the pneumo, use 90732 for the substance and G0009 for the administration.  For a more thorough explanation, go take a look at my Medicare and Immunizations post.  Please remember, not all IPAs have the same fee schedule. If this doesn’t work, a quick call to the provider relations department will point you in the right direction.

3. When Medicare says a patient has an HMO, is Medicare secondary?

No.

Please, let me reiterate.

No. The HMO replaces the patient’s Medicare. The claims go to the HMO. We have to follow the HMO rules. The patient may have a copay and you may need an auth. I am training a front desk right now, and this is the policy I have in place.

If a new patient calls to make an appointment, check the insurance online while the patient is on the phone. It takes 30 seconds to check Medicare on the Noridian Endeavor site. If the patient has an HMO, make a note on the schedule and ask the patient to bring in their HMO card as well as their Medicare card.

If an established patient is returning to the office, go online and check the Medicare eligibility. The status of a patient’s Medicare can change month to month. PLEASE do not assume that if a patient had straight Medicare last month, he will again this month.

Once the doctor performs the service, good luck trying to collect from the patient. People hate to pay after they have already received their service.

So, as always, if you have any questions, please call or email. If you want us to come into your office and train your front desk or your billing department, we can do that. We do on-site training for those in our area and online training and Skype conferences for our far away clients.

EDIT: I have had a couple people ask me what you can do when you see the patient before you find out they have a MR Risk HMO.  You can try billing the patient your cash price. Or, you can send the claim to the IPA (medical group) with your medical records attached asking them to review the charge for a retro authorization based on medical necessity. In box 19 on the physical claim form write “please review notes for retro authorization.” I also like to send a letter. Here is a good example of a medical necessity template appeal letter. And everyone who gets paid due to this can thank Molly and David for their rather pertinent emails.

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Filed under Billing, Doctor's Office, Flu Shot, HMO, Medicare, Pap smears, Pneumo, Vaccinations, Well woman exam

Everything you ever wanted to know about pap smears

**DISCLAIMER**  

***This post was written in 2014 and the rules have changed since then. I am going to be putting up a new post with the new rules updated to ICD10 very soon. There are some major changes to the way the insurances accept the charges and this an old post with the old rules. If you have any questions, and can’t wait for the new post, please email me directly and I will try and help you out.*** 

The first thing about paps is that every insurance pays them differently. To tell the truth, I don’t have most of it memorized. What I do have is a binder, with one page per insurance, and all of the pap rules are laid out there, in alphabetical order.

Of course, I’m going to give those to you. I suggest you do what I do and put them all in a three ring binder. However, I can only give you the PPO pap smear rules, because your HMO contracts will not be the same as the contracts for my doctors. I can show you a few of my HMO rules, though, so when/if you make your own reference sheets you know what the necessary information is.

You CAN get an office visit and a pap smear paid on the same date on the same claim. You just need to use proper modifiers. Also, most insurances allow patients to self refer for their annual exam, so you shouldn’t have to worry about authorizations.

Here are the Pap rules for PPO insurances. For your HMO insurances, all you need to do is call the provider relations department and get a copy of the doctor’s contract. The contract will be fairly short, and very clear about which codes are paid. However, you will need to ask the provider relations people which diagnosis they need to see on the claims.

If you want to review the high risk rules you can find those on the MR website. Here is a link, for the curious.

Remember to follow the blog; you’ll get an email every time I get a new post up. Also, if you have a specific question, please don’t hesitate to email me.

 

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Filed under Billing, Claims, CPT, Doctor's Office, Health Care, ICD9, Medical Billing, Modifiers, Pap smears, Well woman exam