Business Briefs: Are You Prepared to Answer Questions About New Medicare Summary Notices?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   Wound care providers and suppliers are accustomed to two things: 1) submitting claims to Medicare for services and products provided to beneficiaries and 2) reviewing Medicare’s Explanation of Medical Benefits to learn what Medicare paid and what they must charge to the patient or to the patient’s supplemental insurance. However, providers and suppliers are not always comfortable when Medicare patients who live with chronic wounds confront them or their staff with a bill they’ve received.   Some of the most common questions that Medicare patients ask are: “Why does ‘this’ cost so much?” “Why did you bill for something that I did not receive?” and “Why didn’t Medicare pay for ‘this’ or ‘that’?” In some cases, these patients may be referring to the bill you sent them. In other cases, they may be referring to their Medicare Summary Notice (MSN), the statement that informs Medicare beneficiaries about their claims for Medicare services and benefits.   All wound care providers and their staff should always: 1) ascertain whether questions pertain to the bill and/or the MSN, and 2) take the time to assist their patients with billing questions. If the patient was cared for by a physician, podiatrist, or non-physician practitioner in a hospital-based outpatient wound care department (HOPD), the patient will receive two bills: one from the wound care professional and one from the HOPD. In that circumstance, you must clarify whether the patient’s question is regarding the professional bill or the HOPD bill.   Following is some basic information and instruction that you and your staff should provide to Medicare patients:     • A bill itemizes the charge for each medical service, procedure, separately payable drug/biologic, separately payable equipment, and separately payable supply received on a given date of service. Each year Medicare determines the exact amount of money allowed for each service, procedure, and separately payable product. The patient is responsible for paying coinsurance based on the established Medicare allowable rates, not based on the actual charge on the bill.     • The MSN itemizes all services, procedures, and separately payable products that wound care providers and suppliers billed to Medicare in the past 3 months. It shows the portion of the Medicare allowable rate that Medicare paid to the wound care provider/supplier and the coinsurance you may owe, if you do not have supplemental insurance. Medicare mails MSNs every 3 months if you received a Medicare-covered service in that time period. You do not have to wait until you receive the MSN to view claims submitted by a wound care provider/supplier. Medicare claims can be tracked and electronic MSNs are available online at www.mymedicare.gov, Medicare’s secure online service for personalized information regarding benefits and services. Claims are generally available within 24 hours of Medicare receiving and processing the claims.     • Keep receipts and bills, and compare them to the MSN.     • If a bill is paid prior to receiving the MSN, compare the MSN with the bill to ensure the correct amount has been paid.     • If you have other insurance, check to see if it covers anything that Medicare didn’t.     • If an item or service is denied, call your wound care provider/supplier to confirm the correct information has been submitted to Medicare and to the supplemental insurer. If not, the wound provider/supplier may resubmit the Medicare claim and/or supplemental insurance claim.     • If there’s a disagreement with any decision made by Medicare or supplemental insurer, file an appeal.   Now, if you’re thinking, “I don’t have time to discuss the patient’s bill and/or the MSN with everyone,” I’d challenge that thought. No provider should miss this opportunity to discuss Medicare billing and payment questions with patients. Following is the rationale for that mindset:   On March 7, 2012, the Centers for Medicare & Medicaid Services (CMS) announced the redesign of the MSN, which generally describes what Medicare has or has not covered and provides information about the beneficiary’s payment responsibilities. It also describes the process for initiating an administrative appeal when a beneficiary questions a denial of coverage. This MSN redesign is part of a new initiative, “Your Medicare Information: Clearer, Simpler, At Your Fingertips.” The goal of this initiative is to make Medicare information more understandable and more accessible. The new MSN became available shortly after the CMS announcement to Medicare beneficiaries. Early in 2013, paper copies of the redesigned MSN will start to replace the current version that is mailed to beneficiaries on a quarterly basis.   The redesigned MSN includes several features that are new to Medicare beneficiaries, including:     • A clear notice of how beneficiaries should check the MSN for important facts (see Table 1) and potential fraud (see Table 2);     • An easy-to-understand snapshot of the beneficiary’s deductible status;     • A list of providers the beneficiary saw;     • A clear answer to whether the beneficiary’s claims for Medicare services were approved;     • Clearer language overall, including consumer-friendly descriptions for medical procedures;     • Definitions of all terms used in the MSN (see Table 3);     • Larger fonts throughout the MSN to make it more reader-friendly; and     • Information on preventive services available to Medicare beneficiaries.   To view the document and compare it to the former MSN, CMS has posted a side-by-side comparison online at www.cms.gov/apps/files/msn_changes.pdf.   Medicare beneficiaries will now have a better description of the services and products they’ve received, who provided them, the Medicare allowable, their deductible status, their coinsurance responsibility, their right to appeal (including clear appeal instructions), and straightforward instructions for reporting suspected Medicare fraud. Beneficiaries will also be empowered to challenge their provider and/or supplier charges and to report suspected Medicare fraud (with the possibility of receiving a reward). Therefore, wound care providers and staff should take the time to understand the redesigned MSN and to willingly discuss both their bills and the correlating MSN with their Medicare beneficiaries. Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or by emailing kathleendschaum@bellsouth.net.