If You Think “Medicare for All” Is A Good Idea

If you think “Medicare for all” is a good idea, consider the following. 

It is a bit long but, to make my point, the length is necessary.  I received the following  from Medicare.

“We have determined that Medicare cannot make payment on your new patient office or other outpatient visit, typically 45 minutes.  We have also determined that the provider is responsible for the cost of the service.”

Explanation

 Medicare will not allow a new patient visit during a three year time frame following a previous service by the same provider NPI or providers of the same specialty within the same group.  Our files show that your group was paid for a previous service on December 11, 2017.  The charge for the visit on June 14th 2019 is not covered.  Therefore, no further payment can be made on this claim at this time.

Who is responsible for the Bill?

After determining that the service is not payable by Medicare, we must determine who is financially liable for the denied service.  When a service is denied under para 1879(g) of the Social Security Act (the Act)], we must determine if the beneficiary and the provider either knew or could reasonably be expected to know that the item or service would not be payable.  This is known as the limitation on liability provision of para 1879 of the Act

If the beneficiary was informed by their provider in writing, in advance of receiving the service, that Medicare may not make payment [through receipt of an Advance Beneficiary Notice of Non coverage (ABN); the beneficiary may be responsible for the cost of the denied item or service. If the provider knew or could reasonably be expected to know the item or service would not be payable, but the beneficiary did not have such knowledge, then the provider may be responsible for the cost of the denied service

There is no evidence to indicate that the provider notified the beneficiary in advance that the service would not be payable by Medicare.  Therefore, we have determined that the beneficiary did not know and could not know and could not reasonably have been expected to know that the item or service would not be paid

In  addition, we have determined that the provider either knew or could reasonably be expected to know that the service would not be payable.  Additionally, information about payable services is published to the general Medicare Community using manuals, bulletins, memoranda, etc.  Information on payable services is also available on the Medicare websites (Medicare, FCSO.com and CMS.gov).  Therefore, we find there is sufficient evidence that the provider did not notify the beneficiary in writing, before the Services were furnished, that Medicare would likely not pay for the services.  We have also reviewed the claim with regard to the issue of whether the services were not reasonable and necessary.  Because of this, the provider is held liable for the denied services.

There are another two pages to this bureaucratic mumbo-jumbo describing the procedures for appealing this decision, if you can understand what the issue is. 

People have no idea of the misery and aggravation they will face with Government run healthcare.

About Tracy Connors

Tracy D. Connors graduated from Jacksonville University (AA), University of Florida (BA), the University of Rhode Island (MA), and Capella University (Ph.D. with Distinction, human services management, 2013). Ph.D. (Honorary), Leadership Excellence, Jacksonville University, December, 2013. Designated a "Distinguished Dolphin" by Jacksonville University, Feb. 2, 2010.

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