Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
JUNE 2002 NICA NEWS
QUESTIONS AND ANSWERS
Q. My insurance company sent a check to me instead of the doctor. Should I endorse it and send it to the doctor's office?A. No. Medicare and health insurance send payments directly to you for some claims. It can be tempting to endorse a check and send it to a provider as payment for a bill, but this may not be a good idea. Health care providers receive millions of checks from Medicare, other health insurance and patients. A few of them may not reach the proper place or can be lost. When that happens, you may need to prove you paid.
Beneficiaries may have to pay a bill a second time. In one case, a client endorsed the check he received from his supplemental insurance company and sent it to the doctor. Later the doctor's office showed no record of receiving the check and sent a bill for the unpaid balance. The client had no record of his payment. The client's insurance company couldn't produce a copy of the check, and the client had to pay the doctor's bill again.
The patient should contact the doctor's office to determine if a balance is due on their office visit. If a balance is due, the patient should cash the check from the insurance company. The patient should then write their own personal check to the provider, so proper documentation is available on what transpired.
Q. How does Medicare work with my federal retiree insurance?
A. Non-military federal retirees enrolled in fee-for-service plans will find that Medicare pays first for most services. The Federal Employees Health Benefit Plan (FEHBP) pays second to Medicare, or in some cases, pays for the services not covered by Medicare.
Q. How does Medicare work with military federal retirees?
A. Military federal retirees who have served honorably for at least 20 years are entitled to Tricare, which will pay for items that Medicare does not cover, including the $100 Part B deductible. There are no enrollment fees or premiums for TriCare for Life. You must be enrolled in Medicare Part B.
Q. If I am homebound, will Medicare pay a laboratory to come to my home and collect a specimen?
A. Yes, Medicare will cover the cost of a laboratory house call for patients who are homebound or in a nursing home.
Q. If my doctor gave me a prescription for certain lab tests to be performed, will Medicare automatically cover these tests?
A. Even if a person has a prescription from her doctor for laboratory tests, Medicare will not necessarily cover these tests. It is possible that Medicare may not consider the laboratory tests the doctor ordered to be medically necessary based on federal or local Medicare coverage guidelines.
Q. A beneficiary may live in Nebraska, but their laboratory bill got sent to Medicare in another state. Why?
A. The laboratory that was used was outside of Nebraska. Since Medicare makes payments for services based on the location of services, tests done in laboratories out-of-state are billed to the Medicare Carrier responsible for processing claims in that state.
Q. If a person is a Nebraska resident, but spends a few months each winter in Arizona, will the Comprehensive Health Insurance Pool (CHIP) program cover her while she is in Arizona?
A. Yes. As long as she is still a resident of Nebraska, files a Nebraska tax return, and has a home here, the CHIP coverage she uses in Arizona will depend on whether she uses participating providers. Because CHIP is currently administered by Blue Cross Blue Shield of Nebraska (BCBS), it uses the BCBS provider network. She should check with BCBS of Nebraska , the CHIP administrator, to see if she may take advantage of the Arizona BCBS network. BCBS may check to verify that the CHIP policyholder continues to maintain their Nebraska residency.
Q. Medicare denied payment for a visit to my doctor. Do I have the right to appeal?
A. Yes. To appeal, write "Please Review" on the bottom of the Medicare Summary Notice (MSN), sign the back and send it to the Medicare Carrier (address is on the MSN). When appealing, keep in mind the following:
- You must file an appeal within six months of receiving the MSN;
- Keep a copy of the MSN for your records and mail in the signed original;
- Include information to help make your case, such as a letter from your doctor explaining why you needed the service;
- If you get a second denial, you can ask for a Fair Hearing if the claim is at least $100.
Note: NICA has a flier available, "Medicare Appeals & Grievances (Complaints)" which may help you in counseling beneficiaries with their appeals.
Q. How do the latest changes affect the way Medicare pays for ambulances?
A. The new changes affect how much an ambulance service can charge a beneficiary and how much Medicare will pay. Before the April 1, 2002, changes, Medicare paid ambulances on the basis of their actual costs or charges. Medicare didn't have limits on how much could be charged or how much extra a patient might have to pay.
Now Medicare has created a new payment system that pays on the basis of a set fee for each service provided. This is similar to how Medicare pays hospitals, nursing homes, doctors and other health care providers.
Ambulances must now "accept assignment" for Medicare patients. This means the ambulance provider can't bill for more than Medicare approves. No extra charges are allowed. The beneficiary will not pay more than 20% of the approved amount once they have met their annual $100 Medicare Part B deductible.
These changes are going to end the large bills many people have had to pay even when Medicare did cover an ambulance service. The extra charges often were several hundred dollars more than Medicare allowed. Not all supplemental insurance pays the extra charges.
Effort
Whatever course you have chosen for yourself, it will not be a chore but an adventure
if you bring to it a sense of the glory of striving . . .
--David Sarnoff