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Psychiatric Practice & Managed CareFull Access

What to Do When You Discover Long-Time Patient Has Medicare

Published Online:15 Apr 2005https://doi.org/10.1176/pn.40.8.00400025f

The Managed Care Help Line receives calls on a regular basis from APA members who have just learned that patients they had been treating for some time receive their primary coverage through Medicare but had failed to tell the psychiatrist of this fact despite yearly requests for updated insurance information. In most of these cases, the psychiatrist's office had been billing the patient's secondary payer as primary, and because the appropriate reimbursement was being received, nothing appeared to be amiss.

In some cases the doctor finds out that a patient is covered by Medicare only when the patient talks about it during therapy or finally reports it to office staff. In other cases the doctor discovers the patient has Medicare when the secondary payer, which had been paying as if it were the primary insurer, realizes it should have been paying only the patient's Medicare copay and asks the doctor to refund any payment beyond that amount.

Ellen Jaffe, the Medicare specialist in APA's Office of Healthcare Systems and Financing, called the Coordination of Benefits (COB) contractor phone line maintained by the Centers for Medicare and Medicaid Services (CMS) and asked what doctors should do when they discover that a patient has failed to report that he or she is covered by Medicare.

The CMS rep said that if the patient has had Medicare for more than a year but the secondary insurer has not complained, the doctor should start billing properly from that point on and not address the past. However, if the insurer registers a concern, the doctor must return the money he or she received from that payer above the copay and bill Medicare instead.

“Although the CMS rep acknowledged that claims for services more than a year old are routinely denied,” said Jaffe, “he noted that the doctor can appeal and will likely win if he or she can show that the patient had not been forthcoming about being a Medicare beneficiary.”

In the case of one psychiarist who called the Help Line with this problem, the insurance company that was trying to recover its money offered to handle the Medicare billing for the doctor. The CMS rep said such a practice is acceptable.

If you have any questions about this or other Medicare problems, call the Managed Care Help Line at (800) 343-4671 or the COB phone line at (800) 999-1118. ▪