When is the Plan N Copay Applied?

[somarco]

New client about to undergo 6 weeks of radiation therapy for prostate cancer. Someone told him to change to G (like that is going to happen) to avoid paying $20 copay's for each rad.

Wants to know if I can tell him with certainty he won't be charged a copay for each rad treatment.

Yeah, right. Like I want to test my E&O

So I said this.

I cannot guarantee anything with regard to radiation treatment because I have no way of knowing how the facility will bill Medicare. If they use CPT codes 91201 - 91205 or 912111 - 912115 a copay is in order. Otherwise there should be no copay.

Anything else I should tell him or is this correct and enough?

thx

 

[goillini52]

New client about to undergo 6 weeks of radiation therapy for prostate cancer. Someone told him to change to G (like that is going to happen) to avoid paying $20 copay's for each rad.

Wants to know if I can tell him with certainty he won't be charged a copay for each rad treatment.

Yeah, right. Like I want to test my E&O

So I said this.



Anything else I should tell him or is this correct and enough?

thx

Good answer. You don't know how the provider might bill it and you've CYA.

I might tell them to check and see if they can be sure to not bill it under one of the codes you gave them.

 

[vic120]

Wow more spacific then I would have been.You obviously know your stuff. Probably very helpfull

I would just simply say If it is just billed as radiation therapy you pay nothing after deductible, If they bill as office visit as well add $20, If they don't accept assignment add 10%

 

[somarco]

Thanks Tom. He says he is going to check and see which codes they use and get back to me. If they use something different I figure my butt is covered.

Vic, let Dr Google be your friend. I think I used something like "Medicare doctor visit CPT code"

Used these results
Coding "Routine" Office Visits: 99213 or 99214? - Family Practice Management
Commonly Used CPT Codes - Primary Care | BupPractice

 

[vic120]

Thanks Tom. He says he is going to check and see which codes they use and get back to me. If they use something different I figure my butt is covered.

Vic, let Dr Google be your friend. I think I used something like "Medicare doctor visit CPT code"

Used these results
Coding "Routine" Office Visits: 99213 or 99214? - Family Practice Management
Commonly Used CPT Codes - Primary Care | BupPractice

Thanks, I def will

 

[kstein]

Helluva E and O claim there!

 

[somarco]

Helluva E and O claim there!

Hoping to avoid that. Haven't had one in 40 years. No reason to tempt fate now.

 

[kgmom219]

Excellent Response.

And I'm with Vic...more than I would have given.

"I don't know. Its going to depend on the procedure and diagnosis codes. If its coded as an office visit, you will pay the $20 each time. I would contact the billing person at the doctors office"

(And thanks for the example. Used it today when asked why Towers (Texas Instruments) is pushing N.

 

[LostDollar]

This thread came up in the "similar Threads" list below a Plan N Chemo thread.
Just wanted to comment for folks that might stumble on this in the future.
Caveats:
a) I am not an insurance agent.
b) Insurance for situation mentioned below was group health, not MediGap.

My prostate cancer did not require followup radiation, so I can't comment about visits for that.

A more recent family cancer experience did require chemo. In that sequence of treatments, correctly coded Plan N submittals would have included a specialist copay.

(I don't know if medicare allowances differentiate between the designated family doc and specialist-it was important in the group health situation and I just keep it in my head that way.)

Based on what I saw and heard, I would say that sound medical practice for the benefit of the patient (and probably also for the legal protection of the surgeon/oconologist - same in our case) requires a health review prior to subjecting the patient to a new onslaught of hazardous chemicals. Chemo apparently has a number of deleterious side effects, in addition to hair loss, the only other two I can remember at the moment are appetite and neuropathy. Based on current blood chemistry and patient appearance and response to health questions, the specialist makes a decision as to whether the chemo mix will be administered according to original parameters or modified to some new specification.

So, in our case at least, what I as the inexperienced person would have thought of as "chemo", turned into 3 separate components reflected in the insurance carrier's EOBs.

An appointment for chemo was scheduled.
One or two days prior to that a blood draw was scheduled. (EOB one for lab work)
Chemo administration was preceded by an office visit in which the dr's nurse did a detailed health questionaire and then the dr came in to evaluate and discuss current situation with patient. (EOB two for an office visit)
Chemo was then administered with the chemical mixture specified by the doc for that day. (EOB three for chemo) (and as another poster has suggested in another thread, there were a number of procedure codes on that eob)

In a situation like that I think the office visit and relevant copay are perfectly legitimate charges.

 

[gregj]

Wow more spacific then I would have been.