Forum - Questions & Answers
Billing medicare for non-covered service
Hi all,
I am a volunteer Medicare counselor working with seniors, offering free assistance with their insurance issues. A client just brought in a bill from her physician. She had gone to him for the 'free' screening exams offered by Medicare.
Per the MSN, physician billed for and was paid in full by Medicare for:
1) G0101-GA cervical or vaginal screening, pelvic and breast examination.
2) Q0091-GA screening pap smear.
Medicare paid 100% of physician bill for the above.
He also billed Medicare for code 99397-GY established patient periodic preventive medicine exam. Billed $250, Medicare declined as not covered and now physician is billing the patient.
Two questions: 1) was the billing for 99397 permitted, and 2) it is my understanding that his bill for the 99397 should be reduced by the amount that Medicare paid for the two fully-covered preventive tests.
Your input would be most helpful. Thanks so much.
Howard
re: Billing medicare for non-covered service
Basic Medicare Rule: Medicare does not care what you charge for a non-covered preventive service (non-covered), but you may not collect from all payment sources more than your usual charge for the complete preventive service.
Carve out method: Subtract full Medicare allowable from your fee for the preventive service. Example: 99397 is $200, Medicare allowable for G0101 is $37 and for Q0091 is $45. Patients out of pocket responsibility will be: $118 for 99397.
Bill Medicare for G0101 and Q0091. The copay and deductible are waived for these
services. Wait to collect any balance owed for the non-covered portion of the service until supplemental insurance has denied.
Do not forget to get patient to sign ABN for the G0101 and Q0091 services. If Medicare denies them you can collect from the patient or supplemental insurance.
Patient does not have supplemental insurance:
G0101-GA, Q0091-GA billed to Medicare: 99397 billed to patient (payment amount will be total fee for either of the preventive codes minus the Medicare allowable for G0101 and Q0091 as illustrated with the carve-out example above.
