Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

MARCH 2001 NICA NEWS

ISSUES

Timely Filing of Medicare Claims

Every once in awhile we have clients who feel their providers have not submitted their claims to Medicare in a timely fashion. What do Medicare regulations say about the timely filing of claims?

According to the Medicare Part B News, Issue 185, claims must be filed no later than the end of the calendar year in which the services were provided. However, the filing deadline is extended another full year if the service was provided during the last three months. For example:

Date of Service	Last Filing Date
October 1, 1999 - December 31, 1999	December 31, 2001
January 1, 2000 - September 30, 2000	December 31, 2001
October 1, 2000 - December 31, 2000	December 31, 2002
January 1, 2001 - September 30, 2001	December 31, 2002

Claims filed later than the filing limit will be denied. Providers may only collect from the patient the normal coinsurance that would have applied as well as any unmet deductible. Medicare assigned claims filed more than one year from the service date will see the payment reduced by 10%. This 10% reduction cannot be billed to the patient.

Medicare's Payment for Second Opinions

Medicare Part B helps pay for a second opinion just as it helps pay for other doctors' services that are medically necessary. If you have Medicare Part B and are in the Original Medicare program:

Medicare pays 80% of the approved amount for a second opinion. Your share is usually 20% of the Medicare approved amount, after you have paid your $100 annual Part B deductible.
If the second opinion does not agree with the first, Medicare pays 80% of the approved amount for a third opinion.

If you're in a Medicare HMO, you have the right to get a second opinion. Talk to your plan about specific requirements before doing so.

If you are in a private fee-for-service (PFFS) plan, a second opinion for your health problem is covered by Medicare. If the first two opinions are different from each other, the PFFS plan will pay for a third opinion.

NICA has a HCFA publication #02173 available, called "Getting a Second Opinion Before Surgery." If you would like copies, please contact the NICA Program Office.

CAREGIVING

Americans who care for their aging parents say they feel appreciated, and also proud of what they're doing. But more than a third also feel stressed and concerned about juggling elder care with other responsibilities.

28% - Worry about having enough time for a spouse or partner
30% - Worry about having time for themselves
25% - Worry about having enough time for children
38% - Worry about keeping their own health
30% - Have missed work by caring for an aging relative
43% - Fret about ability to care for themselves as they age

Source: Survey of over 800 adults, sponsored by Family Circle and the Kaiser Family Foundation.

HCFA PROMOTES EYE EXAMS FOR PEOPLE WITH DIABETES

The Health Care Financing Administration (HCFA), the American Academy of Ophthalmology (AAO), and the American Optometric Association (AOA) have launched a cooperative effort to increase the dilated eye exam rate among Medicare beneficiaries with diabetes.

The joint initiative seeks to raise public awareness of the connection between diabetes and blindness, and attack barriers--such as payment and transportation issues--that prevent people with diabetes from getting dilated eye exams.

"This shows what teamwork between Medicare and the private sector can do to bring better health care to millions of beneficiaries," said HCFA Administrator Nancy-Ann DeParle. "Obtaining necessary preventive services like dilated eye exams is vitally important for diabetics," said Jeffrey Kang, MD, MPH, director of HCFA's Office of Clinical Standards and Quality and the agency's chief clinical officer. "This collabor-ative effort moves us a big step closer to ensuring that all Medicare beneficiaries with diabetes get the care they need and deserve."

People with diabetes are at an increased risk for eye problems, including blindness, and may need treatment even if their vision is normal. About 10 percent of the Medicare population has diabetes.

HCFA, has identified diabetes as a clinical priority area in which there is a significant opportunity to improve the quality of care provided to Medicare beneficiaries in all states across the nation.

Through its national network of Medicare Peer Review Organizations, which are committed to ensuring quality health care for Medicare beneficiaries, and in partnership with the AAO and AOA, HCFA hopes to positively influence the quality of care received by all Medicare beneficiaries with diabetes.

Medicare has provided a series of new or expanded preventive health care benefits since 1998, including mammograms, pap smears, colorectal cancer screening, bone mass measurement for beneficiaries at risk for osteoporosis and other bone abnormalities, flu and pneumonia vaccinations, glucose monitoring for diabetics and education and training programs for diabetics.

By law, regular fee-for-service Medicare may not cover refractive services -- eye exams for eyeglasses -- although some Medicare+Choice managed care plans may offer them. Medicare does cover medical exams, however, and this new program makes it easier for diabetics to get regular medical eye checkups.

This campaign will provide information about the Foundation of the American Academy of Ophthalmology's EyeCare America - National Eye Care Project (NECP), a program that provides eye care for Medicare beneficiaries age 65 and older who have diabetes and who have not had a medical eye exam in the last three years.

NECP matches qualifying persons with a volunteer ophthalmologist in their area who has agreed to provide a comprehensive medical eye exam and up to one year of follow-up care by that physician for any condition diagnosed at the initial exam, with no out-of-pocket expense to the patient, based on guidelines in an Office of Inspector General advisory opinion (OIG AO 99-7).

Medicare diabetes patients may also qualify for help in receiving an eye examination by calling AOA's Diabetes Hot Line. This program matches patients with a participating optometrist in their area who has agreed to perform a dilated eye examination and provide or arrange for subsequent care.

In cases of financial need, the optometrist may be able to waive the deductible and co-payment a Medicare patient usually pays.

Another barrier preventing Medicare patients with diabetes from receiving eye exams is lack of transportation. HCFA will address this barrier through its PROs. In some cases, PROs may be able to identify state or local community organizations that can provide transportation to eye appointments for Medicare beneficiaries.

PROs will inform Medicare beneficiaries of AAO's and AOA's programs through a series of postcards and brochures sent to qualifying beneficiaries. The project also features a national media campaign including radio and television public service announcements.

To learn more about the joint AAO/AOA/HCFA Diabetes Initiative, beneficiaries may call 1-888-691-9167. For more information about NECP, they may call 1-800-222-EYES

(1-800-222-3937) 24 hours a day, seven days a week. AOA's Diabetes Hot Line is 1-800- 262-3947. Operators are available from 6:00 a.m. - 6:00 p.m. Eastern Standard Time Monday through Friday.