Thursday, July 20, 2006

Medicare Claims: A Tale of Two Headaches (Maybe More)

[posted by dinah]

You know, it's the damnedest thing. A patient came in today and told me she'd called Medicare to ask why she hadn't been reimbursed for her care and they told her they'd never received a claim from the physician. I could swear I filed one. Actually, I could swear I filed the this exact same claim for this exact same patient three times, because that's how many times she's told me that Medicare hasn't received the claim. What I haven't figure out is why they get some of the claims, but not others, when I send them all in the same envelope. It's like the phenomena of the dryer and the missing single sock.

Okay, sometimes they get the claims, they just reject them. There are columns and rows and codes. The language of these things is a mystery to me: I was ranting at a patient recently (much as I love to rant, there are a limited number of things I can rant to patients about and I've decided that Medicare claims are one of them) about how I couldn't even understand the forms they send me and "I don't even know what coins is!" referring to the name of one of the columns. It was the patient who told me he imagined it stood for Co-Insurance. Wow, I thought, assuming he could be right, it was this Eureka moment where I got an answer after years of subconsciously wondering, only to have my bubble burst when it occurred to me that I didn't know what Co-insurance meant any more than I knew what Coins meant.

Some of the codes are subscripted with sentences that approach English. Some of my claims are returned with "PR-42", PR means "Patient Responsibility. Amount that maybe billed to a patient or another party." 42 means "Charges exceed our fee schedule or maximum allowable amount. Only the fee I charge is the fee determined by Medicare as the limiting fee for a non-participating physician in a non-facility; as a psychiatrist, I only bill for a few codes (mostly 50 minute psychotherapy session with medication management), so what is it sometimes deemed wrong and not other times? And then there's MA130: "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocesssable. Please submit a new claim with the complete/correct information." It would be so nice if they told me What information is incomplete or invalid. And of course, there's MA28: "Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does naot make he physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice." There's nothing like being succinct.

My favorite Medicare form story: a couple of years ago, Medicare announced that the physician's name, address, & phone number-- information which I have on a handy little rubber stamp designed to make it fit in the space-- needed to be placed in box #32. Before that, the information needed to be placed in box #33. They put this in a bulletin and somehow I didn't see it. A patient complained he couldn't get reimbursed, and since this pre-dated the time when a significant portion of my claims were 'not received,' I called for the patient. After sitting on hold for 25 minutes, I was told I hadn't placed my info in box #32. I pointed out that the exact same information was available to anyone who wanted to look in the immediately adjacent Box #33, but I suppose it's hard to shift one's eyes those few millimeters (please forgive my sarcasm here...). Funny, but not a single psychiatrist I asked had seen the bulletin, some had simply been wondering why they or their institution hadn't been paid in months.