RE: Hi Everyone,

[Guest guest]

Hi Teri, you're mixing up Disability & Renal rules (ha ha, who hasn't?!) W/renal rules the size of the group doesn't matter. If the pt is in an employer group health plan, the COB period applies, period, regardless of how restrictive the benefits.

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-----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ]On Behalf Of Terianne CowlingSent: Tuesday, February 21, 2006 4:46 PMTo: TxFinancialCoordinators Subject: Hi Everyone,Hi Everyone,I have a question concerning the instance by where Medicare becomes Primary during the COB period for an ESRD patient. As I understand it, Medicare becomes Primary when the patient is in an LGHP in which the plan covers fewer than 100 employees or the plan denies the claim because the benefits are exhausted or the services are not covered under the plan. If a patient with ESRD is employed in a large corporation but has really poor medical coverage, e.g. payment of $400 per day for hospital room and board only and no coverage of professional fees, the patient's LGHP would remain Primary during the COB period because the company has more than 100 employees, right? Thank you.Teri CowlingTFCUT Southwestern Medical Center

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[Guest guest]

As I understand it, Medicare becomes Primary when the patient is in an LGHP in which the plan covers fewer than 100 employees or the plan denies the claim because the benefits are exhausted or the services are not covered under the plan. [Aguiar, (Surgery)] Sort of.

Pt 65+, employer group 20+ = GHP primary, Medicare 2ndy.

Pt 65+, employer group less than 20 = Medicare prime.

Pt -65, employer group 100+ = GHP primary, Medicare 2ndy.

Pt -65, employer group -100 = Medicare prime.

**Note, it is the #of employees working for the company/organization, NOT the #of employees enrolled in the GHP (an example of this would be a self-employed real estate broker getting ins thru the local Chamber of Commerce; it is the #of people in the CoC which will determine the 'group' size for COB purposes, not the #of people in the real estate office).

ESRD Pt, regardless of age or size of the employer group, w/a GHP Medicare is 2ndy for the 1st 30 months due to ESRD COB.

Amount of coverage provided by a commercial policy has no bearing on whether it is primary or not-you will still need to bill the private ins, & follow their guidelines, if it is primary based on any of the criteria above, & then balance bill Medicare w/the EOB from the private ins, for payment after.

J. Aguiar

Beth Israel Deaconess, Boston

f a patient with ESRD is employed in a large corporation but has really poor medical coverage, e.g. payment of $400 per day for hospital room and board only and no coverage of professional fees, the patient's LGHP would remain Primary during the COB period because the company has more than 100 employees, right? Thank you.Teri CowlingTFCUT Southwestern Medical Center

[Guest guest]

Hi ,

Thank you for the information! So... Would a patient with ESRD who has insurance

through his employer and is still in his COB period rely solely on EGHP

(primary) for coverage or would Medicare be billed (secondary) when his EGHP

benefits are exhausted? In other words, should only the benefits offered by

this ESRD patient's primary insurance carrier be considered when determining the

financial suitability of the patient for kidney transplant? Thank you very

much.

Teri

>>> LAguiar@... 2/22/2006 12:08:07 PM >>>

As I understand it, Medicare becomes Primary when the patient is in an

LGHP in which the plan covers fewer than 100 employees or the plan

denies the claim because the benefits are exhausted or the services are

not covered under the plan.

[Aguiar, (Surgery)] Sort of.

Pt 65+, employer group 20+ = GHP primary, Medicare 2ndy.

Pt 65+, employer group less than 20 = Medicare prime.

Pt -65, employer group 100+ = GHP primary, Medicare 2ndy.

Pt -65, employer group -100 = Medicare prime.

**Note, it is the #of employees working for the company/organization,

NOT the #of employees enrolled in the GHP (an example of this would be a

self-employed real estate broker getting ins thru the local Chamber of

Commerce; it is the #of people in the CoC which will determine the

'group' size for COB purposes, not the #of people in the real estate

office).

ESRD Pt, regardless of age or size of the employer group, w/a GHP

Medicare is 2ndy for the 1st 30 months due to ESRD COB.

Amount of coverage provided by a commercial policy has no bearing on

whether it is primary or not-you will still need to bill the private

ins, & follow their guidelines, if it is primary based on any of the

criteria above, & then balance bill Medicare w/the EOB from the private

ins, for payment after.

J. Aguiar

Beth Israel Deaconess, Boston

f a patient with ESRD is employed in a large corporation but has really

poor medical coverage, e.g. payment of $400 per day for hospital room

and board only and no coverage of professional fees, the patient's LGHP

would remain Primary during the COB period because the company has more

than 100 employees, right? Thank you.

Teri Cowling

TFC

UT Southwestern Medical Center

[Guest guest]

Teri,

You should include all of the patient's benefits to determine the financial

suitability of the patient for kidney transplantation. You will need to

assess the patient's financial responsibility based on what will be covered

by both Payors. Medicare will pay up to Medicare liability. If you are a

Medicare approved provider, and accept assignment of benefits, then the

provider can only collect from the patient Medicare co insurance and

deductible which will be stated on the Medicare EOB.

Austria

Specialty Contracting

Methodist Health System

1441 North Beckley Avenue

Dallas,Texas 75203

Phone:

Fax:

RE: Hi Everyone,

Hi ,

Thank you for the information! So... Would a patient with ESRD who has

insurance through his employer and is still in his COB period rely solely on

EGHP (primary) for coverage or would Medicare be billed (secondary) when his

EGHP benefits are exhausted? In other words, should only the benefits

offered by this ESRD patient's primary insurance carrier be considered when

determining the financial suitability of the patient for kidney transplant?

Thank you very much.

Teri

>>> LAguiar@... 2/22/2006 12:08:07 PM >>>

As I understand it, Medicare becomes Primary when the patient is in an

LGHP in which the plan covers fewer than 100 employees or the plan

denies the claim because the benefits are exhausted or the services are

not covered under the plan.

[Aguiar, (Surgery)] Sort of.

Pt 65+, employer group 20+ = GHP primary, Medicare 2ndy.

Pt 65+, employer group less than 20 = Medicare prime.

Pt -65, employer group 100+ = GHP primary, Medicare 2ndy.

Pt -65, employer group -100 = Medicare prime.

**Note, it is the #of employees working for the company/organization,

NOT the #of employees enrolled in the GHP (an example of this would be a

self-employed real estate broker getting ins thru the local Chamber of

Commerce; it is the #of people in the CoC which will determine the

'group' size for COB purposes, not the #of people in the real estate

office).

ESRD Pt, regardless of age or size of the employer group, w/a GHP

Medicare is 2ndy for the 1st 30 months due to ESRD COB.

Amount of coverage provided by a commercial policy has no bearing on

whether it is primary or not-you will still need to bill the private

ins, & follow their guidelines, if it is primary based on any of the

criteria above, & then balance bill Medicare w/the EOB from the private

ins, for payment after.

J. Aguiar

Beth Israel Deaconess, Boston

f a patient with ESRD is employed in a large corporation but has really

poor medical coverage, e.g. payment of $400 per day for hospital room

and board only and no coverage of professional fees, the patient's LGHP

would remain Primary during the COB period because the company has more

than 100 employees, right? Thank you.

Teri Cowling

TFC

UT Southwestern Medical Center

[Guest guest]

Okay. Thank you so much!

Teri

>>> Austria@... 2/23/2006 3:05:41 PM >>>

Teri,

You should include all of the patient's benefits to determine the financial

suitability of the patient for kidney transplantation. You will need to

assess the patient's financial responsibility based on what will be covered

by both Payors. Medicare will pay up to Medicare liability. If you are a

Medicare approved provider, and accept assignment of benefits, then the

provider can only collect from the patient Medicare co insurance and

deductible which will be stated on the Medicare EOB.

Austria

Specialty Contracting

Methodist Health System

1441 North Beckley Avenue

Dallas,Texas 75203

Phone:

Fax:

RE: Hi Everyone,

Hi ,

Thank you for the information! So... Would a patient with ESRD who has

insurance through his employer and is still in his COB period rely solely on

EGHP (primary) for coverage or would Medicare be billed (secondary) when his

EGHP benefits are exhausted? In other words, should only the benefits

offered by this ESRD patient's primary insurance carrier be considered when

determining the financial suitability of the patient for kidney transplant?

Thank you very much.

Teri

>>> LAguiar@... 2/22/2006 12:08:07 PM >>>

As I understand it, Medicare becomes Primary when the patient is in an

LGHP in which the plan covers fewer than 100 employees or the plan

denies the claim because the benefits are exhausted or the services are

not covered under the plan.

[Aguiar, (Surgery)] Sort of.

Pt 65+, employer group 20+ = GHP primary, Medicare 2ndy.

Pt 65+, employer group less than 20 = Medicare prime.

Pt -65, employer group 100+ = GHP primary, Medicare 2ndy.

Pt -65, employer group -100 = Medicare prime.

**Note, it is the #of employees working for the company/organization,

NOT the #of employees enrolled in the GHP (an example of this would be a

self-employed real estate broker getting ins thru the local Chamber of

Commerce; it is the #of people in the CoC which will determine the

'group' size for COB purposes, not the #of people in the real estate

office).

ESRD Pt, regardless of age or size of the employer group, w/a GHP

Medicare is 2ndy for the 1st 30 months due to ESRD COB.

Amount of coverage provided by a commercial policy has no bearing on

whether it is primary or not-you will still need to bill the private

ins, & follow their guidelines, if it is primary based on any of the

criteria above, & then balance bill Medicare w/the EOB from the private

ins, for payment after.

J. Aguiar

Beth Israel Deaconess, Boston

f a patient with ESRD is employed in a large corporation but has really

poor medical coverage, e.g. payment of $400 per day for hospital room

and board only and no coverage of professional fees, the patient's LGHP

would remain Primary during the COB period because the company has more

than 100 employees, right? Thank you.

Teri Cowling

TFC

UT Southwestern Medical Center

[Guest guest]

You absolutely should be looking @ all the ins coverage a pt has when determining financial suitability for tx, but one thing you need to keep in mind, Teri, is that if you have a situation where the pt has a Cigna or URN policy primary, which REQUIRES the pt to use their COE facility for the commercial payer to make any payment, Medicare will NOT pay (make up the difference if you will) if the pt elects to disregard that COE requirement-there is a ltr from CMS in the 3rd Edition of the Resource Guide that deals w/this issue specifically.

Hope this helps,

J. Aguiar

Beth Israel Deaconess, Boston

From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Terianne CowlingSent: Thursday, February 23, 2006 3:32 PMTo: TxFinancialCoordinators Subject: RE: Hi Everyone,

Hi ,Thank you for the information! So... Would a patient with ESRD who has insurance through his employer and is still in his COB period rely solely on EGHP (primary) for coverage or would Medicare be billed (secondary) when his EGHP benefits are exhausted? In other words, should only the benefits offered by this ESRD patient's primary insurance carrier be considered when determining the financial suitability of the patient for kidney transplant? Thank you very much.Teri

[Guest guest]

Thank you . It definitely helps.

Teri Cowling

UT Southwestern Medical Center

>>> LAguiar@... 2/24/2006 8:32 AM >>>

You absolutely should be looking @ all the ins coverage a pt has when

determining financial suitability for tx, but one thing you need to keep

in mind, Teri, is that if you have a situation where the pt has a Cigna

or URN policy primary, which REQUIRES the pt to use their COE facility

for the commercial payer to make any payment, Medicare will NOT pay

(make up the difference if you will) if the pt elects to disregard that

COE requirement-there is a ltr from CMS in the 3rd Edition of the

Resource Guide that deals w/this issue specifically.

Hope this helps,

J. Aguiar

Beth Israel Deaconess, Boston

________________________________

From: TxFinancialCoordinators

[mailto:TxFinancialCoordinators ] On Behalf Of Terianne

Cowling

Sent: Thursday, February 23, 2006 3:32 PM

To: TxFinancialCoordinators

Subject: RE: Hi Everyone,

Hi ,

Thank you for the information! So... Would a patient with ESRD who has

insurance through his employer and is still in his COB period rely

solely on EGHP (primary) for coverage or would Medicare be billed

(secondary) when his EGHP benefits are exhausted? In other words,

should only the benefits offered by this ESRD patient's primary

insurance carrier be considered when determining the financial

suitability of the patient for kidney transplant? Thank you very much.

Teri