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Making a Medicare or Insurance Claim

By Robert (Bob) Weiss, MS, LE Legislative Advocate

In past columns I have reported on lymphedema mandate progress at the state and federal (Medicare) levels, as well as changes in statutes and policies as they affect lymphedema stakeholders. Looking back over six years of reporting, I notice an inexorable shrinking of access to lymphedema treatment services due to incremental changes in Medicare and insurance policies. This decreased coverage occurs in spite of growing need for lymphedema treatment, improved education of physicians, growing number of trained therapists and recognition by the Lymphedema Panel of the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) that there is evidence that complex decongestive therapy (CDT) and sequential compression pneumatic devices are helpful in the treatment of lymphedema. The net result of these policy changes is a growing number of claims denials.

Filing a Claim http://www.medicare.gov/Basics/FAC.asp

Enrolled Providers. In Original Medicare (Medicare fee-for-service), doctors and suppliers are required by law to file Medicare claims for covered services and supplies they provide. Effective March 1, 2008 all claims were required to have the provider's National Provider Identifier (NPI) on the claim signifying that the provider is enrolled in Medicare. Your providing physician's NPI may be searched at https://nppes.cms.hhs.gov/NPPES/Welcome.do where you can find out which doctors in your area are enrolled in Medicare and which accept assignment.

Other Providers. Medicare Advantage plans don't file claims because Medicare pays these health management organizations (HMOs) a set amount every month for each Medicare patient. Claims for lymphedema services not provided by private insurance companies are filed with the insurer according to the procedures detailed in the Evidence of Coverage (EoC).

Participating and Non Participating Suppliers. If you expect to be reimbursed by Medicare for your supplies, make sure your supplier is enrolled in the Medicare Program. If you go to a supplier that is not enrolled, Medicare will not pay and you will be responsible for paying the entire bill. You can find local Medicare enrolled suppliers and pharmacies by entering your ZIP Code into the online supplier directory at http://www.medicare.gov/Supplier/.

For Medicare covered supplies, you should also find out if your pharmacy or supplier is participating with Medicare.

  • If they are participating, they must accept assignment. This means they must accept the Medicare-approved amount as payment in full. You should only pay your 20% co-pay (and any remaining annual Medicare Part B deductible) when you get your supplies. The online supplier directory will tell you if the pharmacy or supplier is participating with Medicare.
  • If they are not participating, they do not have to accept assignment. This means that charges may be higher, and you may pay more. You may also have to pay the entire charge at the time of service, and wait for Medicare to send you its share of the charge when you win your appeal.

Participating suppliers will probably tell you that your prescribed compression item is "not covered by Medicare". They will ask you to sign a CMS Form R-131 Advance Beneficiary Notice of Noncoverage (ABN). Signing signifies that you understand that the supplier believes that Medicare does not cover the item and the claim will be denied. You will have to pay for the item up front. On the ABN, select "OPTION 1" which forces the supplier to file a claim and protects your right to file an appeal when the claim is denied.

If you have paid the non-participating supplier the full cost of the item(s), request that the supplier enter the statement, "Patient refuses to assign benefits" in Item 19 of the 1500 Claim Form. In this case, payment will be made directly to the Beneficiary (you) if the claim denial is reversed in the appeal process.

Strictly Enforced Timeliness Requirements. A Medicare claim must be filed no later than one calendar year from the date the service was received (Date of Service or DoS). Check the Medicare Summary Notice (MSN) you get in the mail every three months to make sure claims are being filed in a timely manner. If you do not see the item listed on your MSN covering the Date of Service, contact your doctor or supplier and ask them if they have filed a claim. If they didn't file the claim, call 1-800-MEDICARE and ask for the exact time limit for filing a Medicare claim for the service or supply that you received. Medicaid claims may be subject to shorter filing times, e.g. California MediCal claims must be received by the Fiscal Intermediary within six months of the DoS. If you approach the deadline for filing a claim and your doctor or supplier still hasn't filed one, it's time for you to file a claim on your own.

Beneficiary-Submitted Claims. CMS Form 1490s Patient's Request for Medical Payment is used to file a claim for reimbursement for Part B services such as an MLD treatment with bandaging and patient care instruction. It is also used to file a claim for reimbursement for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) which include compression bandages, garments and devices which have been prescribed by your Medicare-enrolled physician and provided by a Medicare-enrolled supplier.

Filling out the Claim Form. The key information you should put into Box 4 are words like " (Item description) was prescribed by Dr. (physician's name and National Provider Identifier) as medically necessary for treatment of patient's lymphedema, (ICD-9-CM diagnostic code 457.0, 457.1 or 757.0). This item when used as part of the compression treatment of lymphedema meets the coverage criteria in the Medicare Benefit Policy Manual CMS Pub. 100-02, Chapter 15, section 120 Prosthetic Devices.

Send Your Claim to the Correct Medicare Contractor. The Medicare Administrative Contractor (MAC) to which the form is sent is different for Part B services than it is for DMEPOS items. Find the address for your location by going to http://www.cms.gov/CMSForms/, choosing "CMS Forms" in the left-hand margin, selecting "show only items containing the word 1490s", and selecting the Form Number 1490s in the list. You may download the instructions in English or Spanish, with separate instructions including the addresses appropriate to use for Part B service claims or DMEPOS item claims.

Send the completed claim form, your itemized bill, and any supporting documents to the appropriate Medicare Administrative Contractor and explain in detail your reason for submitting the claim. For example, include a statement that notifies the MAC that your provider or supplier refused or is unable to file a claim for a Medicare-covered service and/or is not enrolled with Medicare.

What to Expect— At the current time, Medicare contractor interpretation of Medicare coverage rules will probably result in a denial of your claim for compression bandages, garments and devices. In order to take advantage of the appeals process a claim for payment must have been submitted to the appropriate MAC and a written denial issued by that MAC.

Conducting a Medicare or Insurance Appeal: Space does not permit discussion of the details of conducting a Medicare or insurance appeal of a lymphedema claim denial. A useful brochure that was created January 2011 by Medicare for its contractors may be downloaded at https://www.cms.gov/MLNProducts/downloads/MedicareAppealsprocess.pdf and an excellent process flow chart is available at http://www.cms.gov/OrgMedFFSAppeals/Downloads/AppealsProcessFlowchartAB.pdf. Although the brochure describes "The Medicare Appeals Process; Five Levels to Protect Providers, Physicians, and Other Suppliers", it is applicable also, with small changes, to the protection of Beneficiaries.

If you need individualized help with your Medicare or insurance claim for lymphedema services or materials, you may contact the writer for help. I am not a lawyer or a physician, and cannot give legal or medical advice, but I may be able to assist you through the healthcare maze and receive the medical treatment to which you are entitled. I require no payment for my services.

Robert "Bob" Weiss, M.S.