If I understand you correctly, you expected that an HMO would be the payor, but they say Medicare is primary. I don't know whether this person had two insurers (HMO and Medicare) or one (member of a Medicare HMO).
If the person has insurance through a job, and also has Medicare, either one could be primary depending on the circumstances. The Medicare manual gives specifics. When there is doubt about which one is primary, the safest thing to do is to do the PPS assessments just in case. They should be transmitted before the deadline for transmission, or else you can bill only at the default rate if it turns out that Medicare is primary.
You are in a similar situation when you believe that a person is a member of a Medicare HMO and you plan to bill the HMO. But you find out later on that he or she disenrolled from the HMO and went back to traditional Medicare. It is a good idea to do and transmit PPS assessments for members of Medicare HMOs to avoid getting caught without having done them when you find out about a disenrollment. Again, if the deadline for doing and/or transmitting has passed, you can bill only at the default rate.
In your situation, you are well past the deadline for transmitting. The resident was with you in November, and the deadline for transmitting is 31 days after the completion date. Transmitting it now wouldn't help. You are still limited to billing at the default rate, whether you would transmit it or not.
You also asked about changing the coding from insurance to Medicare. That would be appropriate if you were still within the window for transmitting. If there is an error and we haven't transmitted yet, we should correct the error first.
From: "Richardson, Christine" <[EMAIL PROTECTED]> Reply-To: [EMAIL PROTECTED] To: <[EMAIL PROTECTED]> Subject: FW: Medicare verses HMO Date: Thu, 26 Feb 2004 11:00:20 -0600
Second try. > -----Original Message----- > From: Richardson, Christine > Sent: Thursday, February 26, 2004 7:59 AM > To: '[EMAIL PROTECTED]' > Subject: Medicare verses HMO > > > > Hope some one might have had this problem. > > Problem: Res admitted in November under HMO.ARD set at day 5 but was not > transmitted d/t res discharged prior to initial assessment. > Now HMO denying claim, says Medicare is primary. The assessment was > completed in the correct time frame but wasn't transmitted. It is coded > for Insurance and no Medicare. > > Should I leave it the way it is? Change the codes to reflect Medicare > need? > Do I call some one since it will be transmitted late? > > I really, really need help! > > Thanks in advance > Christine Richardson LPN/CRNAC > Nursing Assessment Coordinator >
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The Case Mix Discussion Group is a free service of the
American Association of Nurse Assessment Coordinators
"Committed to the Assessment Professional"
Be sure to visit the AANAC website. Accurate answers to your
questions posted to NAC News and FAQs.
For more info visit us at http://www.aanac.org
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