Medicare Designated Rural Hospital

[ExProgrammer]

I can put that link anywhere but here somehow.

I googled "rural hospital, accepts medicare assignment"

a couple of entries down, it reads "Rural Health Clinics (RHCs) Introduction-Rural Health Information Hub"

also this PDF link:

https://www.cms.gov/Outreach-and-Education/Medicare.../RuralHlthClinfctsht.pdf

Does her plan cover Part B excess charges? "Medicare Part B Excess Charges. ... A doctor who accepts the Medicare assignment would bill at or below that rate. However, your medical provider may decide that $500 is not a sufficient reimbursement. Providers are allowed to charge up to an additional 15% over and above what Medicare has approved."

As an outpatient procedure (I assume), this would apply. PA doesn't allow it, but GA does.

That's really odd that the link gets changed after you paste it. I had the same problem with it, even using the "Insert Link" button. Anyway, what it's doing is replacing the "ru" in rural with "xyz". So if you click on the link, then change it to "rural" instead of "xyzral" in your address bar it will work. Or copy the link and open a new window or tab in your browser, paste it, then change it before you press [Enter].

https://www.xyzralhealthinfo.org/topics/rural-health-clinics

 

[somarco]

Thanks ExP.

The revised link for rural hospitals does offer this insight on Medicare reimbursement.

RHCs receive an interim all-inclusive reimbursement payment rate per visit throughout the clinic's fiscal year, which is then reconciled through cost reporting at the end of the year. According to the FORHP's Starting a Rural Health Clinic - A How-To Manual, the interim payment rate is determined by taking total allowable costs for RHC services divided by allowable visits provided to RHC patients receiving core RHC services. In addition, RHCs are subject to productivity standards that can affect payment.

This hospital is not in their first year and I still don't see anything that indicates the rural hospital or CAH can refuse the Medicare payment as paid in full.

Still think the problem lies in the MSN or services performed that were not deemed medically necessary.

Thanks for all the contributions including undercover Jen calling for her grandmother.

 

[somarco]

UPDATE

Client provided me with her MSN for this hospital claim. Can't say I have ever seen one like this where, apparently Medicare did not discount the billed charges. Can anyone explain this?

 

[LostDollar]

1) The amount stated as paid by medicare in post one is apparently incorrect.

2) Although the medicare approved amount has not been marked down, the hospital is limiting its claim to patient to the amount which Medicare says may be billed to the patient. (The sum of the amounts already paid by Medigap and the amount the hospital is seeking to recover from patient.)

If this was my situation, I would now be asking Medigap why they did not pay the additional amount I am obligated for per the MSN.


Edit one:
I'm figuring either Medicare made a mistake or there is a special deal relating to the "rural hospital" situation. I would hope that the Medigap response would give me the next clue as to what to ask about or object to.

Edit two:
It also looks to me like the amount unpaid may be the anchor screw and injections. So:
1) Maybe those charges did not get sent to the Medigap company?
or
2) There is an issue to be resolved between Medicare and Medigap as to whether the Anchor and Injection codes are allowable Medicare procedures?

 

[MBSC]

This is a CAH. The Part B cost share is 20% of CHARGES. The system is coded to calculate 20% of the approved amount as the cost share so the charge has to be moved to the approved amount field to correctly calculate the cost share.

Add "amount you can be billed" to "amount Medicare paid" to obtain the true approved amount. The true approved amount is less than the billed charge. The billed charges have been discounted.

CAHs are paid for most inpatient and outpatient services to Medicare patients at 101 percent of reasonable costs. CAHs are not subject to the Inpatient Prospective Payment System (IPPS) or the Hospital Outpatient Prospective Payment System (OPPS).

CAH services are subject to Medicare Part A and Part B deductible and coinsurance amounts. The copayment amount for most outpatient CAH services is 20 percent of applicable Part B charges and is not limited by the Part A inpatient deductible amount.

The Centers for Medicare & Medicaid Services (CMS) encourages CAHs to engage in consumer-friendly communication with patients about their charges to help patients understand their potential financial liability for services they may obtain at the CAH.

Reference: https://www.cms.gov/Outreach-and-Ed...LNProducts/downloads/critaccesshospfctsht.pdf

 

[kgmom219]

What they said.

And the anchor thingy. Its accidental dental (I'm assuming), they can't do it without the anchor. So I would also assume that Medicare thinks the anchor billing is part of a different line of the claim.

2nd question: Are we 100% sure the supplement has processed the claims?

 

[somarco]

Thanks for the insight MBSC. Very much appreciated.

Medigap paid $3838.74 per the client. I have not seen the carrier EOB so cannot confirm this number.

But if Medicare paid $1736.28 and Medigap (G plan and deductible satisfied earlier in the year) I am still having trouble following the numbers.

Claim $29,528.79
Medicare paid $1736.28
Medigap paid $3838.74 which, according to MBSC should be 20% of the charges (or is it the approved amount?).

$3838.74 divided by 20% = $19,193.70 which is presumably the allowable charge by Medicare. But they only paid $1736.28.

Where is the rest of the money and why is the hospital claiming the patient still owes them $2067.02?

And to make it more interesting, this email from my client has this line.

St Marys first bill dated 4/2/17 to me said: "total charges: $29528.79; payments/adjustments -23623.03; account balance: $5905.76." Then, I got a later statement from St Marys dated 4/12/17 saying "total charges/balance carried forward $5905.76; payments/adjustments $3838.74; account balance $2067.02."


The hospital does accept assignment so why do they still want money? I have asked client to go to hospital and ask for an explanation. She has yet to do that.

Arghhh!

Oh, and the helpful folks at 800-MEDICARE said the outstanding balance was probably because some Medicare supplement plans don't pay very well.

 

[Todd King]

Thanks for the insight MBSC. Very much appreciated.

Medigap paid $3838.74 per the client. I have not seen the carrier EOB so cannot confirm this number.

But if Medicare paid $1736.28 and Medigap (G plan and deductible satisfied earlier in the year) I am still having trouble following the numbers.

Claim $29,528.79
Medicare paid $1736.28
Medigap paid $3838.74 which, according to MBSC should be 20% of the charges (or is it the approved amount?).

$3838.74 divided by 20% = $19,193.70 which is presumably the allowable charge by Medicare. But they only paid $1736.28.

Where is the rest of the money and why is the hospital claiming the patient still owes them $2067.02?

And to make it more interesting, this email from my client has this line.

St Marys first bill dated 4/2/17 to me said: "total charges: $29528.79; payments/adjustments -23623.03; account balance: $5905.76." Then, I got a later statement from St Marys dated 4/12/17 saying "total charges/balance carried forward $5905.76; payments/adjustments $3838.74; account balance $2067.02."


The hospital does accept assignment so why do they still want money? I have asked client to go to hospital and ask for an explanation. She has yet to do that.

Arghhh!

Oh, and the helpful folks at 800-MEDICARE said the outstanding balance was probably because some Medicare supplement plans don't pay very well.

Yep, that must be true because we all know that each carrier has different plans that vary from one company to the next, and we also know that the insurance companies can choose not to pay simply because they don't want to.

 

[sman]

Oh, and the helpful folks at 800-MEDICARE said the outstanding balance was probably because some Medicare supplement plans don't pay very well.

More proof that they don't know their a$$ from a hole in the ground. The sad part is if they tell the beneficiary this, they will believe it because hey, it's Medicare and they must know what they're talking about.

 

[LostDollar]

The hospital is billing because Medicare says they can.

You've got to get some info from the Medigap carrier.

There may be some deductibles playing around in there somewhere too.