Guest guest Posted August 24, 2000 Report Share Posted August 24, 2000 Nadine, We had a similar situation arise here, but Medicare wasn't involved. A liver patient had two insurance policies, the primary was out of network, but the secondary was " in " . The secondary would not pay if the primary denied charges based on out-of-network stipulations. I realize the scenario changes quite a bit when Medicare is secondary (i.e. M'care often dictates insurance reg's, not the other way around), and I don't have the answer for you, but I THINK M'care would not pay upon retrospective review. (Although I could be swayed to think otherwise!) Amy Kaye Children's Chicago TFC Questions Hi everyone: I would like to get your opinion on a couple of issues that have come up recently to see what everyone else's experience has been. The first case involves a K/P recipient who was transplanted prior to dialysis. This patient has two private insurance plans, one through active employment and one is a retiree plan from previous employment. My question is this: Is there any reason why she has to apply for Medicare at this time? Will her EGHP's require her to sign up because of the COB period when Medicare would be primary? Does she have anything to lose by not signing up? My next question involves kidney patients enrolled in a PPO plan that does not contract with my institution. If the patient opts out of network for tx, will Medicare pay up to the DRG on the IP admission as the secondary payor? Our fiscal intermediary tells me that they will pay unless the patient is enrolled in a Medicare HMO but other people I talk with seem to be a little hesitant thinking that Medicare may retract payment based on retrospective review. Any thoughts or opinions would be appreciated. Thanks and have a great day!! Nadine Gruidl UMC, Las Vegas - Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 24, 2000 Report Share Posted August 24, 2000 Nadine I'm not sure but I know there are times Medicare will pay if there is a deniel from the primary insurer but I'm not sure about transplant. >>> akaye@... 08/24/00 09:35AM >>> Nadine, We had a similar situation arise here, but Medicare wasn't involved. A liver patient had two insurance policies, the primary was out of network, but the secondary was " in " . The secondary would not pay if the primary denied charges based on out-of-network stipulations. I realize the scenario changes quite a bit when Medicare is secondary (i.e. M'care often dictates insurance reg's, not the other way around), and I don't have the answer for you, but I THINK M'care would not pay upon retrospective review. (Although I could be swayed to think otherwise!) Amy Kaye Children's Chicago TFC Questions Hi everyone: I would like to get your opinion on a couple of issues that have come up recently to see what everyone else's experience has been. The first case involves a K/P recipient who was transplanted prior to dialysis. This patient has two private insurance plans, one through active employment and one is a retiree plan from previous employment. My question is this: Is there any reason why she has to apply for Medicare at this time? Will her EGHP's require her to sign up because of the COB period when Medicare would be primary? Does she have anything to lose by not signing up? My next question involves kidney patients enrolled in a PPO plan that does not contract with my institution. If the patient opts out of network for tx, will Medicare pay up to the DRG on the IP admission as the secondary payor? Our fiscal intermediary tells me that they will pay unless the patient is enrolled in a Medicare HMO but other people I talk with seem to be a little hesitant thinking that Medicare may retract payment based on retrospective review. Any thoughts or opinions would be appreciated. Thanks and have a great day!! Nadine Gruidl UMC, Las Vegas - Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 24, 2000 Report Share Posted August 24, 2000 I have had these same conversations with our Fiscal Intermediary. They have informed me that if the patient has a choice to go to a center for full benefit payment, they are not responsible for paying as the secondary payer. Our intermediary asks us to let them know if this is happening and they will send the patient notice prior to their transplant regarding this issue. Also, from my payer background, some plans PPO, HMO or indemnity may require patients to pick up Medicare when it is available. If the patient chooses not to enroll, they are allowed by law to deduct the Medicare allowable and pay only what they would pay if the patient had enrolled in Medicare. The patient is then responsible for the Medicare portion. I have had some payers actually pay the Medicare premiums for patients if they can't afford them...obviously it is in their best interest to pay the premium plus the secondary payment rather than pay the entire claim. Becky Joest Clarian Health Indiana University Hospital > TFC Questions > > > Hi everyone: > > I would like to get your opinion on a couple of issues that have come up > recently to see what everyone else's experience has been. > > The first case involves a K/P recipient who was transplanted prior to > dialysis. This patient has two private insurance plans, one through > active > employment and one is a retiree plan from previous employment. My > question > is this: Is there any reason why she has to apply for Medicare at this > time? Will her EGHP's require her to sign up because of the COB period > when > Medicare would be primary? Does she have anything to lose by not signing > up? > > My next question involves kidney patients enrolled in a PPO plan that > does > not contract with my institution. If the patient opts out of network for > tx, will Medicare pay up to the DRG on the IP admission as the secondary > payor? Our fiscal intermediary tells me that they will pay unless the > patient is enrolled in a Medicare HMO but other people I talk with seem to > be a little hesitant thinking that Medicare may retract payment based on > retrospective review. > > Any thoughts or opinions would be appreciated. Thanks and have a great > day!! > > Nadine Gruidl > UMC, Las Vegas > > > > - > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 24, 2000 Report Share Posted August 24, 2000 , Would your Fiscal Intermediary be willing to send you a copy of this policy from the Registry, or identify the volume and page number this policy can be found? TFC Questions > > > Hi everyone: > > I would like to get your opinion on a couple of issues that have come up > recently to see what everyone else's experience has been. > > The first case involves a K/P recipient who was transplanted prior to > dialysis. This patient has two private insurance plans, one through > active > employment and one is a retiree plan from previous employment. My > question > is this: Is there any reason why she has to apply for Medicare at this > time? Will her EGHP's require her to sign up because of the COB period > when > Medicare would be primary? Does she have anything to lose by not signing > up? > > My next question involves kidney patients enrolled in a PPO plan that > does > not contract with my institution. If the patient opts out of network for > tx, will Medicare pay up to the DRG on the IP admission as the secondary > payor? Our fiscal intermediary tells me that they will pay unless the > patient is enrolled in a Medicare HMO but other people I talk with seem to > be a little hesitant thinking that Medicare may retract payment based on > retrospective review. > > Any thoughts or opinions would be appreciated. Thanks and have a great > day!! > > Nadine Gruidl > UMC, Las Vegas > > > > - > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 24, 2000 Report Share Posted August 24, 2000 I have a the reference somewhere in one of these piles on my desk. I will find it when I have a moment and site it for all. bj > TFC Questions > > > > > > Hi everyone: > > > > I would like to get your opinion on a couple of issues that have > come up > > recently to see what everyone else's experience has been. > > > > The first case involves a K/P recipient who was transplanted prior > to > > dialysis. This patient has two private insurance plans, one > through > > active > > employment and one is a retiree plan from previous employment. My > > question > > is this: Is there any reason why she has to apply for Medicare at > this > > time? Will her EGHP's require her to sign up because of the COB > period > > when > > Medicare would be primary? Does she have anything to lose by not > signing > > up? > > > > My next question involves kidney patients enrolled in a PPO plan > that > > does > > not contract with my institution. If the patient opts out of > network for > > tx, will Medicare pay up to the DRG on the IP admission as the > secondary > > payor? Our fiscal intermediary tells me that they will pay unless > the > > patient is enrolled in a Medicare HMO but other people I talk with > seem to > > be a little hesitant thinking that Medicare may retract payment > based on > > retrospective review. > > > > Any thoughts or opinions would be appreciated. Thanks and have a > great > > day!! > > > > Nadine Gruidl > > UMC, Las Vegas > > > > > > > > - > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 25, 2000 Report Share Posted August 25, 2000 I finally found the Medicare Reg regariding this issue..It is not the full reg..so unfortunately I can't site it for you, however if you send me your fax numbers I will fax what our intermediary sent me. Thanks, Becky Joest Clarian Health Indiana University > TFC Questions > > > > > > Hi everyone: > > > > I would like to get your opinion on a couple of issues that have > come up > > recently to see what everyone else's experience has been. > > > > The first case involves a K/P recipient who was transplanted prior > to > > dialysis. This patient has two private insurance plans, one > through > > active > > employment and one is a retiree plan from previous employment. My > > question > > is this: Is there any reason why she has to apply for Medicare at > this > > time? Will her EGHP's require her to sign up because of the COB > period > > when > > Medicare would be primary? Does she have anything to lose by not > signing > > up? > > > > My next question involves kidney patients enrolled in a PPO plan > that > > does > > not contract with my institution. If the patient opts out of > network for > > tx, will Medicare pay up to the DRG on the IP admission as the > secondary > > payor? Our fiscal intermediary tells me that they will pay unless > the > > patient is enrolled in a Medicare HMO but other people I talk with > seem to > > be a little hesitant thinking that Medicare may retract payment > based on > > retrospective review. > > > > Any thoughts or opinions would be appreciated. Thanks and have a > great > > day!! > > > > Nadine Gruidl > > UMC, Las Vegas > > > > > > > > - > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 25, 2000 Report Share Posted August 25, 2000 Please include me in the routing! My fax is . Thank you!! Amy Kaye CMH Chicago TFC Questions > > > > > > Hi everyone: > > > > I would like to get your opinion on a couple of issues that have > come up > > recently to see what everyone else's experience has been. > > > > The first case involves a K/P recipient who was transplanted prior > to > > dialysis. This patient has two private insurance plans, one > through > > active > > employment and one is a retiree plan from previous employment. My > > question > > is this: Is there any reason why she has to apply for Medicare at > this > > time? Will her EGHP's require her to sign up because of the COB > period > > when > > Medicare would be primary? Does she have anything to lose by not > signing > > up? > > > > My next question involves kidney patients enrolled in a PPO plan > that > > does > > not contract with my institution. If the patient opts out of > network for > > tx, will Medicare pay up to the DRG on the IP admission as the > secondary > > payor? Our fiscal intermediary tells me that they will pay unless > the > > patient is enrolled in a Medicare HMO but other people I talk with > seem to > > be a little hesitant thinking that Medicare may retract payment > based on > > retrospective review. > > > > Any thoughts or opinions would be appreciated. Thanks and have a > great > > day!! > > > > Nadine Gruidl > > UMC, Las Vegas > > > > > > > > - > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 25, 2000 Report Share Posted August 25, 2000 THANKS BECKY !! FAX ... MSC UNMC OMAHA TFC Questions > > > > > > Hi everyone: > > > > I would like to get your opinion on a couple of issues that have > come up > > recently to see what everyone else's experience has been. > > > > The first case involves a K/P recipient who was transplanted prior > to > > dialysis. This patient has two private insurance plans, one > through > > active > > employment and one is a retiree plan from previous employment. My > > question > > is this: Is there any reason why she has to apply for Medicare at > this > > time? Will her EGHP's require her to sign up because of the COB > period > > when > > Medicare would be primary? Does she have anything to lose by not > signing > > up? > > > > My next question involves kidney patients enrolled in a PPO plan > that > > does > > not contract with my institution. If the patient opts out of > network for > > tx, will Medicare pay up to the DRG on the IP admission as the > secondary > > payor? Our fiscal intermediary tells me that they will pay unless > the > > patient is enrolled in a Medicare HMO but other people I talk with > seem to > > be a little hesitant thinking that Medicare may retract payment > based on > > retrospective review. > > > > Any thoughts or opinions would be appreciated. Thanks and have a > great > > day!! > > > > Nadine Gruidl > > UMC, Las Vegas > > > > > > > > - > > > > > > Quote Link to comment Share on other sites More sharing options...
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