Medicare Designated Rural Hospital

[somarco]

What the heck is a Medicare designated rural hospital? Client in south Georgia had bunion surgery in late January. Says the surgery was "pre-approved by Medicare".

I explained that pre-approved means snot and nothing is paid until Medicare reviews the claim.

Medicare paid $5905, Medigap paid $3838 but hospital claims she still owes $2067.

I have asked her to review her MSN and/or send to me for review. Also suggested calling Medicare for an explanation.

Subsequent correspondence produced this response.

" It seems that because this brand new spanking hospital is classified as a "rural" hospital, they pay them less and so now St Mary's is turning around and asking me to pay the difference. "

This is a new one on me.

I have never heard the term "rural hospital" and any special rules regarding Medicare. Googling rural hospital seems to indicate hospitals that qualify for grants. So far have found nothing that states they must accept Medicare assignment.

My understanding is, any hospital that receives federal funds MUST accept assignment. Oddly, when searching Medicare.gov for hospitals that accept assignment I come up empty. Maybe I looked in the wrong place. I can find docs and other medical facilities that accept assignment, but nothing in the hospital search addresses the issue.

Trying to get information from this client is like nailing Jello to a wall. I have encouraged her to call and discuss by phone but she prefers email.

So what the heck is a rural hospital? Are they required to accept assignment? Can they balance bill for approved charges?

The hospital is
ST MARY'S GOOD SAMARITAN HOSPITAL
5401 LAKE OCONEE PARKWAY
GREENSBORO, GA 30642

Any help appreciated.

 

[traceyemoon]

Good luck with your Jello nailing

In PA, in the Western region, we have a few of those. Mostly because we have two major MAPDs fighting over clients in the urban areas. We sell a decent amount of Med Supps because people don't want to be limited to either of the two groups of hospitals.

Here is the CMS list of approved rural medical facilities, though I didn't see your specific hospital in there.

https://www.cms.gov/Outreach-and-Ed...nProducts/Downloads/rhclistbyprovidername.pdf

found the list and quite a few other topics about rural health here: https://www.ruralhealthinfo.org/topics/rural-health-clinics

hope it helps!

 

[vic120]

I am watching this thread I have a client in SC that is mailing me hosp bills to look at, She has plan F Medicare paid Her Supp paid but hosp said she still owes 2K in addition to what was paid, The Supp company says impossible, Hosp said these are what's left over and needs to be paid no other explanation

 

[somarco]

Thanks for the info, Tracey. Link#2 didn't work for me.

I failed to mention that I asked my client if she signed an ABN form, making her liable for claims denied by Medicare. She doesn't think she did.

 

[traceyemoon]

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.

 

[MBSC]

St. Mary's is a Critical Access Hospital (CAH). This is the technical term Medicare uses for their designated rural hospitals. You may have more luck researching that term.

The Rural Health Clinics (RHC) mentioned in another post are a different type of provider.

CMS CAH: https://www.cms.gov/medicare/provid...ification/certificationandcomplianc/cahs.html

St. Mary’s Good Samaritan Hospital was recently named one of the top 20 critical access hospitals (CAHs) for Quality in the country.

Reference: St. Mary's Good Samaritan Hospital | Good Samaritan named to Top 20 Critical Access Hospital list | Athens GA

 

[kgmom219]

This one intrigued me.....

There are 2 different providers:
1. Rural Health Clinic (would only bill Part B)
2. Critical Access Hospital (Hospital that satisfies a bunch of requirements)

There are special Medicare rates for clinics or hospitals that are designated as RHC or CAH. However, they are still not allowed to balance bill.

I actually called Medicare and got a good rep. (Told her it was for my grandma!)
She said its crap. Asked that I call in with grandma and her Medicare number. If A&B paid, then Plan F, that's all they get and they shouldn't balance bill. She was pissed. She really wants the return call so she can report them to whoever for fraud.

And if it is Excess Charges (and it shouldn't be, anyway) then Plan F would have covered that, too.

Let us know Bob.

 

[somarco]

Does her plan cover Part B excess charges?

Yes, plan G.

Thanks for the links MBSC, but I see nothing about the ability to refuse Mcare assignment. Link to the hospital's site shows they accept A & B.

Thanks for lying, Jen. You would make a good undercover reporter.

I told my client to call Medicare again and ask the same question. Figure she will get a different rep and different answer.

She has G which does cover xs.

Wish my client would send me her MSN. That might answer a lot. Nailing Jello and not making progress.

 

[ExProgrammer]

Yes, plan G.

Thanks for the links MBSC, but I see nothing about the ability to refuse Mcare assignment. Link to the hospital's site shows they accept A & B.

Thanks for lying, Jen. You would make a good undercover reporter.

I told my client to call Medicare again and ask the same question. Figure she will get a different rep and different answer.

She has G which does cover xs.

Wish my client would send me her MSN. That might answer a lot. Nailing Jello and not making progress.

What does MSN stand for?

 

[Ronnie Carter]

What does MSN stand for?

It's a Medicare Summary Notice, which details what Medicare paid and, perhaps, refused to pay, for a beneficiary. Kind of like an EOB (Explanation of Benefits) statement.

Too many acronyms in this business.