Medicare Excess Charges in ER

somarco

GA Medicare Expert
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Atlanta
More often the ER in smaller hospitals is staffed in part by contract employees. Seems like I read some time ago that providers who contract with a Medicare participating hospital must accept assignment.

Perhaps that is incorrect. Can't say since I can't find any reference addressing that issue.

Going beyond the issue of non-par providers who may accept assignment or not would be providers who opt out of Medicare completely.

Given the requirement of notifying the patient prior to accepting services from an opt-out provider, I would assume anyone who contracts with a hospital is either par or non-par.

So we are back to non-par providers who contract with a hospital in any capacity, including ER. Are such providers allowed to forgo assignment?

Even if they are, it would seem that the likelihood of collecting a high percentage of any xs charges would be slim. ER's are money losers for most hospitals given the number of people who are uninsured as well as others who may have the ability to pay but simply choose not to.
 
More often the ER in smaller hospitals is staffed in part by contract employees. Seems like I read some time ago that providers who contract with a Medicare participating hospital must accept assignment.

Perhaps that is incorrect. Can't say since I can't find any reference addressing that issue.

Going beyond the issue of non-par providers who may accept assignment or not would be providers who opt out of Medicare completely.

Given the requirement of notifying the patient prior to accepting services from an opt-out provider, I would assume anyone who contracts with a hospital is either par or non-par.

So we are back to non-par providers who contract with a hospital in any capacity, including ER. Are such providers allowed to forgo assignment?

Even if they are, it would seem that the likelihood of collecting a high percentage of any xs charges would be slim. ER's are money losers for most hospitals given the number of people who are uninsured as well as others who may have the ability to pay but simply choose not to.

I agree with the 1st sentence, but can't find the reference, either.

I DO know that a recent med school grad who is doing her ER doc residency told me she had to sign up for Medicare assignment because that's the "rule" and she actually did it as soon as she was matched (as did her fellow grads).
 
Would having the (emergency) services provided at a non participating hospital solve the questions??
 
Any hospital that receives govt $$ is required to accept assignment. If they treat Medicare or Medicaid patients they must accept assignment.

My question addresses care or services provided by contract health care workers who are not staff employees. A video referenced in another thread discussing plan N and xs charges makes mention of a client that incurred over $2,000 in non-covered xs charges in an ER setting.

Medicare allows xs charges but limits them. Xs charges arise when services are provided by a health care worker that does not accept assignment. Doctors with admitting privileges are (I believe) required to accept assignment. An ER doc that contracts with a hospital, directly or indirectly, would have admitting privileges. It seems unlikely a Medicare patient would incur xs charges in an ER setting.

Perhaps this question is best posed to a carrier.
 
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Yes.

I have hit and gone past the point I was trying to tell Todd about in another thread where my memory is now giving me problems on these issues. I can't remember a good amount of things that I know I have looked up before for threads-I just have to look things up again.

One possibility that occurred to me is that you and kgmom may be remembering things that you found out when you had the rural hospital thread awhile back. Not sure, and I haven't the heart to go back and redo all the reading I did for that because it will just go away again.

I think the things I was seeing yesterday go along with what you posted about xs charges, but I still stick with my question about non-participating emergency providers.

I have not watched the video much further than the point you describe because I did not have the time or the interest to try to follow east coast med supp pricing variations. In the discussion you are referencing though, the point was made that the patient had no say in choice of facility or caregivers.

As I searched, I saw lots of discussion about emergency health situations and the indication that doctors; unenrolled, enrolled and non-participating, and enrolled and opted-out; could all bill medicare for emergency health treatments-form references were provided.

I also saw a CMS billing manual page that referenced non-participating hospitals. If there is a need to reference such an animal in a manual, there must be some. I think about my community. The urban sprawl puts high end residences, high end shopping centers and new doctor owned medical facilities all together.

I am speculating that on the heavily populated (?) eastern seaboard there may be some population concentrations that are wealthy enough to make some private doctor owned medical facilities viable. Maybe that would include some heart clinics-doctor owned-fee based no government help wanted.

So suppose someone in a wealthy neighborhood had a heart attack and their life was at risk. Suppose that the closest facility which could deal with heart attacks was a small private non-participating clinic which met all the requirements of an emergency facility. The patient is taken there, treated to the point where further treatment is not "emergency" and then moved again to a participating hospital with participating doctors.

The non-participating clinic/hospital then bills Medicare at the non-participating rates. In regard to the patient billed portion, one would presume a public figure would probably not risk the embarrassment of unpaid medical bills.

Those are the speculations in my mind as I asked the question.
 
Very few hospitals that do not accept Medicare assignment. Public and most privately owned hospitals accept Medicare assignment. Shriner's hospitals and St Jude accept Medicare. Mayo hospital accepts assignment but some of their outpatient clinics do not. Cedars-Sinai accepts Medicare assignment.

I suppose there are some hospitals, privately funded, that are not required to accept Medicare patients, that do not take assignment but I challenge you to find one.

I did reach out to a carrier that knows me very well and asked about xs charges for ER. They said they pay "very few" xs claims from ER and the amount is nominal. Granted, that is not definitive but pretty much confirms my suspicion that incurring xs charges in an ER would be extremely rare.

FWIW, I spot checked a few of the larger hospitals (by # of beds) on Becker's list and did not find any that do not participate in Medicare.
 
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If the hospital has an ER and has a sign displayed saying they will stabilize and treat all patient or treat all women in labor, it accepts Medicare. The sign is required by EMTALA and it means the hospital accepts government money.

I challenge anyone to find a hospital with an ER that does not accept government money. It may exist, but I would have to see it to believe it. The realities of an ER mean lots of people without insurance or have Medicare, Medicaid or VA. It would be tough to financially survive or provide enough patients for the doctors to remain certified and competent without them.

Somarco mentioned St. Jude, not too far from me. While they may not accept Medicare, no patient pays for care. They will bill any and all insurance, but any remaining balance is absorbed by their fund raising. St. Jude also does not have an ER and does not have the staff to provide emergency care. Hardly an example to look at in how it is handled.
 
Urgent care may or may not be affiliated with a local hospital. Regardless, urgent care is not the same as emergency room.

Kirby, as you should know, St Jude is a unique patient care and research facility. According to their website, 75% of funding is from private donations. Balance comes from insurance (including Medicare and Medicaid) and private payments.
 
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Urgent care may or may not be affiliated with a local hospital. Regardless, urgent care is not the same as emergency room.

Kirby, as you should know, St Jude is a unique patient care and research facility. According to their website, 75% of funding is from private donations. Balance comes from insurance (including Medicare and Medicaid) and private payments.

I know, which is why I said it is different. I wasn't sure of the breakdown, I just know their general policy. Speaking of which, one most people are not aware of, they do not treat just any child with cancer. As one of their primary missions is research, they focus on children with cancers they are currently researching for treatment and management.

Hard not to know someone who doesn't work there or FedEx in this town.

I have the pleasure of knowing the guy who does a lot of their art work, amazing guy and amazing stuff.

Youngblood Studio
 
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