Helpful Information for Medicare Patients
The following information should be considered by patients covered by Medicare as a primary or secondary payer.
• Why am I billed for some of the medication I am given while receiving services at the Hospital as an outpatient?
• What is "medical necessity?"
• What is the purpose of an advanced beneficiary notice (ABN)?
• What are non-covered services?
• If Medicare does not pay for a test, does that mean that I do not need the test?
• What options do I have?
• Why am I asked to complete a Medicare Secondary Payer questionnaire?
Why am I billed for some of the medication I am given while receiving services at the Hospital as an outpatient?
During the course of your outpatient treatment, you may be given medication that is considered self-administered by Medicare. Medicare defines self-administered drugs as medications that you could, in another setting, take yourself.
In order to remain compliant with Medicare regulations related to the billing of these drugs, medical providers are required to submit these self-administered drugs as non-covered items on our billing to Medicare.
You will receive a bill from us following payment of our claim by Medicare. In addition to any deductible and co-insurance due, this bill will reflect charges for self-administered drugs. Payments for these items will be expected from you. However, you may be able to receive reimbursement under Medicare Part D, if you are enrolled in Medicare Part D. For more information regarding self-administered drugs, refer to your "Medicare and You" handbook, or call Medicare at 800-633-4227.
What is "medical necessity?"
Medicare covers only those services which are reasonable and necessary for your treatment as documented by the ordering physician. Medicare requires providers to report information regarding your diagnosis, symptoms or risk factor when seeking payment so that they can determine whether the services ordered were medically necessary. The Social Security Act defines medically necessary as:
1. Consistent with the symptoms or diagnosis of the illness/injury;
2. Within generally accepted professional medical standards;
3. Not performed primarily for the convenience of the patient, physician or medical supplier; and
4. Furnished at a level of care that is safe and effective for the patient.
What is the purpose of an advanced beneficiary notice (ABN)?
Medicare has established guidelines to ensure that all tests or procedures performed on you are medically necessary. If the diagnosis does not meet Medicare’s established criteria for medical necessity, payment for the claim will be denied.
As the provider of care, it is our responsibility to notify you prior to testing if the diagnosis supplied by the physician does not meet Medicare’s medical necessity guidelines. In these cases, you will be asked to sign an Advanced Beneficiary Notice (ABN) acknowledging that you are aware that Medicare may not pay the claim and accept financial responsibility for payment.
What are non-covered services?
Non-Covered services are those services excluded for payment by the Medicare program. Examples include dental, cosmetic, and self-administered drugs received during an outpatient visit. Charges for non-covered services are the responsibility of the patient. For more information please visit www.Medicare.gov. Or, call Medicare at (800) 633-4227.
If Medicare does not pay for a test, does that mean that I do not need the test?
No. Your physician bases decisions about testing on a wide range of factors including such things as your personal medical history, any medications you might be taking and generally accepted medical practices. Even if your physician believes a test will provide useful information to give you the best care, it is possible that Medicare may not consider the test to be medically necessary for your diagnosis.
What options do I have?
You have two options when an ABN form is presented to you. You may:
1. Agree to be responsible for payment of services if Medicare does not consider them reasonable and necessary and receive the services, or
2. Refuse to be responsible for payment and therefore not receive the tests or services.
Why am I asked to complete a Medicare Secondary Payer questionnaire?
Medicare requires that medical providers obtain certain types of information from you each time a test or procedure is performed. Your responses to the questions are used to ensure that Medicare is not billed for charges that may be the responsibility of another payment source. For example, if you were seeking treatment for an automobile accident, any accident insurance would need to be billed prior to billing Medicare.
Some of the information collected on this questionnaire is maintained in your permanent Social Security record and each claim submitted on your behalf is matched to this record. We understand that answering these questions each time you are treated can be an inconvenience, however, it is extremely important that we adhere to Medicare requirements and that we submit the most accurate information available.