Medicare Designated Rural Hospital

...why is the hospital claiming the patient still owes them $2067.02?

The hospital does accept assignment so why do they still want money?
Regarding the Medigap, the amount Medicare paid is irrelevant. The patient's responsibility is $5905.76. Since the deductible has been met, this amount becomes the Plan G responsibility. The question is why did the Plan G pay exactly 65% to the penny ($3838.74) of their responsibility?

The hospital is only looking to collect the amount they are "currently" entitled to, the difference between the patient responsibility and Medigap underpayment. The hospital does not realize the Medigap has underpaid.
 
I can't come up with a clearly stated page I can link to, but with the 65% as a clue, I saw one thing that suggests to me the Medigap carrier may be trying to do a "reasonable and customary" negotiation with Medicare or with the hospital-not sure which.
 
The question is why did the Plan G pay exactly 65% to the penny ($3838.74) of their responsibility?

I have no answer on that. Carrier won't tell me. HIPAA rules. This is driving me nuts. Thanks again for your input.
 
If you cannot visit with the client to make the call, then try a conference call between you and the carrier so permission can be given to allow you to get the info needed.

I have no answer on that. Carrier won't tell me. HIPAA rules. This is driving me nuts. Thanks again for your input.
 
More hunting on the 65%.

I can not come up with any neat tidy links but following are possibilities which I'm seeing.

CAH Critical Access Hospital.
ASC Ambulatory Surgery Center.

ASC might be paid at 65% of billed amounts.

MSN might have been issued as though facility is a CAH.

For some reason Medigap thinks facility is an ASC and is paying accordingly.

Resolution? Speak with facility billing department-get documentation of the actual registered category of the facility; then force hospital and medigap to process claims in that way, using CMS complaint procedures if necessary?

MSN implies that CMS sees facility as CAH, not ASC, and that hospital is processing correctly and that Medigap is processing incorrectly?
 
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Mystery solved.

Finally got enough info from client to piece it together. Contacted VP I know at the carrier. Explained the situation. She looked into it and got back to me about 15 minutes later.

They use a third party repricing company that is able to reduce OP hospital claims by 35%. Either someone at the hospital didn't know or the hospital decided not to go along with the repricing.

Carrier has contacted repricing company who in turn is going to hit up the hospital. Carrier said if hospital won't play ball they (carrier) will pay the claim, making the client whole.

They also asked if there were other claims outstanding. Today I received 6 bills, 5 from the hospital, another from an imaging center, that also are asking for more money. Total outstanding, including the $2k from Good Sam, is around $2600.

Client is happy. I am happy.

I am aware this carrier and others use a 3rd party repricing firm but this is the first time I have seen it in action.

Thanks to all for your insight and contributions but seems the answer was more simple than all the machinations we went through.
 
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whats the name of the carrier?

Mystery solved.

Finally got enough info from client to piece it together. Contacted VP I know at the carrier. Explained the situation. She looked into it and got back to me about 15 minutes later.

They use a third party repricing company that is able to reduce OP hospital claims by 35%. Either someone at the hospital didn't know or the hospital decided not to go along with the repricing.

Carrier has contacted repricing company who in turn is going to hit up the hospital. Carrier said if hospital won't play ball they (carrier) will pay the claim, making the client whole.

They also asked if there were other claims outstanding. Today I received 6 bills, 5 from the hospital, another from an imaging center, that also are asking for more money. Total outstanding, including the $2k from Good Sam, is around $2600.

Client is happy. I am happy.

I am aware this carrier and others use a 3rd party repricing firm but this is the first time I have seen it in action.

Thanks to all for your insight and contributions but seems the answer was more simple than all the machinations we went through.
 
I am going to open up a can of worms and say that its nice to see the agents with Med Supp members have customer service issues to deal with and not just us Medicare Advantage agents and our MAPD members. I know there are a lot fewer customer service issues with Med Supps than MAPD plans.
 
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