Billing / Insurance

IMPORTANT information from CMS on the new Medicare cards:

5 Ways for Healthcare Providers to Get Ready for New Medicare Cards starting April 2018

Medicare is taking steps to remove Social Security numbers from Medicare cards. Through this initiative the Centers for Medicare & Medicaid Services (CMS) will prevent fraud, fight identity theft and protect essential program funding and the private healthcare and financial information of our Medicare beneficiaries.

CMS will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN) both on the cards and in various CMS systems we use now. We’ll start mailing new cards to people with Medicare benefits in April 2018. All Medicare cards will be replaced by April 2019.

CMS is committed to helping providers by giving them the tools they need. We want to make this process as easy as possible for you, your patients, and your staff. Based on feedback from healthcare providers, practice managers and other stakeholders, CMS is developing capabilities where doctors and other healthcare providers will be able to look up the new MBI through a secure tool at the point of service. To make this change easier for you and your business operations, there is a 21-month transition period where all healthcare providers will be able to use either the MBI or the HICN for billing purposes.

Therefore, even though your systems will need to be able to accept the new MBI format by April 2018, you can continue to bill and file healthcare claims using a patient’s HICN during the transition period. We encourage you to work with your billing vendor to make sure that your system will be updated to reflect these changes as well.

Beginning in April 2018, Medicare patients will come to your office with new cards in hand. We’re committed to giving you information you need to help your office get ready for new Medicare cards and MBIs.


FAQs

If I am a subscriber to the Ambulance Association, why am I getting a bill?
Federal law requires that if you bill one patient you must bill everyone. With this there are certain discounts we can provide if you are a subscriber with us. We bill your Insurance for you and then after they pay we can adjust certain portions left unpaid. Deductibles CANNOT be written off and must be collected as this is an agreement between you and the Insurance carrier and is responsibility as part of your plan benefits.
I have Insurance. Don’t they cover this service?
Insurance is NEVER a definite on coverage of different services. All carriers follow Medicare guidelines on what is a covered service and since Medicare has cut coverage most other Insurance carriers see this as a way they can save money and deny a service. There is never a guarantee on coverage by any Insurance.
I do not have any Insurance. What are my payment options?
If you do not have Insurance we will certainly work with you. We understand these are circumstances most people do not envision needing an ambulance. You may contact our office directly at 717-569-6622 or you may go to the Payment Calculator section to submit a payment schedule. You may also click here and it will take you direct to the credit card form to complete and submit to us.
I cannot afford this billing as I am on a fixed income. Do you forgive or reduce my billing?
We have many payment options for you to use. You may make monthly payments by calling our office or by scheduling a routine payment via credit card on a monthly basis, and you may also submit a payment via check or money order. We try to assist the patients and their families as much as we can.
If I received a check from the Insurance company, how do I make payment on my account?
We only participate with Medicare and Traditional Medicaid in Pennsylvania. Other Insurance carriers will submit the payment directly to the patient. When received you may endorse and undersign by stating “pay to the order of MTAA” below your signature on the check. You may deposit the check and send us a personal check, a certified check, money order, or by placing the amount on a credit or debit card. If payment is sent to the patient, it is your responsibility to make full payment to us. Any claims paid to you and not sent to us are then sent to collection and a 25% or higher fee will be attached to the outstanding balance. A copy of the Explanation of Benefits should be copied and submitted to us with your payment.
If I only received a portion of the billed amount from my Insurance company, do you accept this as payment in full?
If the Insurance does not pay in full, this is usually a result of your benefit plans. Many carriers try to pay less to save money. When this happens we always advise you to contact the carrier as we balance bill ALL partial payments. We only accept Medicare and Medicaid as payment in full. If you are a subscriber, we may be able to give a reduction as long as it is not a deductible. This is why it is important we receive a copy of your explanation of benefits to assist us with any reductions we may be able to provide.
If I am a subscriber and the Insurance sent me the check, do I still need to pay this billing to you?
Yes. If not this is considered theft of services. The billing was submitted on your behalf but it is not a way to make money. This would be considered fraud as you were not the person or service providing service to you. We also report these to the IRS each year.
I have Insurance and want to provide this information to you, how do I go about getting this information to you in a more timely fashion?
You may contact us direct or complete a form found here and submit it to us. We always need a signature on file in order to submit a billing to ALL Insurance carriers. Different carriers have different addresses for which they wish to have claims sent. It is important we obtain this information to submit to the correct location for proper claims processing. All claims are due net 45 days and can be submitted to collection after that time. This is the same time frame carriers have to process a claim or they must pay interest on the claim so they wish the claim submitted as quickly as possible.
Are all billings for ambulance service covered by most Insurances?
Not all Insurance carriers pay for ambulance services. There is NO in-network provider for ambulance services on a 911 call. If the Insurance wishes to pay less for an out-of-network provider so we ask that you please advise them you have NO control on whose service you will receive by dialing 911. Certain Insurance carriers pay for certain things.
Why do you need my signature in order to bill my Insurance?
We need your signature for billing so the Insurance carriers know that you were transported on a certain date and that you are agreeing you had the service. We are required to obtain a signature for each and every time you receive a service from us.
I called 911 but was not transported. Do I still get a billing for this service?
Yes. All services are billed in one fashion or another. If you or someone else called 911 and a vehicle is dispatched and you are evaluated and decide not be transported you will still receive a billing. It still costs us to respond and while we are tied up with you we could be missing another call. If you are a subscriber it will be at a lower cost than if not a subscriber. There is also a fee should we come out just to pick you off the floor as well.
Are wheelchair van services covered by Medicare and/or Medicaid?
Wheelchair van services are NOT covered by Medicare. Medicare only pays for ambulance service and only if it meets medical necessity under Medicare’s new guidelines which are very limited. See policy below direct from CMS website. If you are On Medicaid you will be asked to sign a form advising of personal responsibility for payment prior to being transported. In some cases we may ask for payment up front.

Medicare does not cover the following services:
  • Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs.
  • Transportation via Mobile Intensive Care Unit (MICU) ( if billed under Medicare Part A).
  • Parking fees.
  • Tolls for bridges, tunnels and highways.
  • Medicare does not provide payment for "Ambulance response and treatment, no transport (A0998)."
Does a claim need to be submitted to the Insurance?
No. All persons have the right to pay the claim on their own without any information being submitted to the Insurance carrier. These types of claims are required to be paid in full within 60 days.

Manheim Township Ambulance Association only participates with Medicare and Pennsylvania Medicaid and NO other carriers. We will bill all carriers on your behalf but we DO NOT accept any partial payment as payment in full.  It will be the responsibility of the patient to pay any and all outstanding balances. Discounts to those balances, minus a deductible will be provided to those who are subscribers to the association.

ALL Patients have the right to have a claim excluded from Insurance processing so NO information is submitted to any carrier. Under these circumstances, in so doing, the patient is then agreeing to pay out-of-pocket the full billed amount so no claim is generated to any insurance carrier.

Any claim submitted to ANY Highmark Blue Shield or Capital Blue Cross plan will be the responsibility of the patient as they will send the money to the patient since we are non-participating. They will not provide us any information on these claims under a privacy rule they have set up and it is the patients responsibility to contact the carrier for claim status.

We do accept credit cards for payment (Visa, Mastercard, Discover and American Express only), please complete this form.

All claims not paid within 60 days and the patient has not called to make payment arrangements will be submitted to collection and an additional 25% fee is added at that time. It is also reported to all 3 credit bureau reporting agencies.

For Medicare & Medicare Advantage plans, please complete this Patient Insurance Information/Authorization form.

Billing Coverage Issues:

A misconception is that whenever a call is made via 911 it will be paid. ALL carriers are trying to have more patient financial responsibility when it comes to healthcare and payment for services. A claim submitted must meet criteria which is different than what a physician or hospitals are reimbursed. Ambulances have been set with a limited diagnosis and medical necessity requirement for all claims.

Having Insurance whether Private or from a State or Federal program DO NOT constitute payment. All claims processing are based on diagnosis codes. ALL carriers follow federal programs and changes to those programs went into effect in April of 2012. When Medicare dropped a huge segment of the over 30,000 diagnosis codes and allocated only 73 of those for billing, all carriers followed these same guidelines in order to save money. In times past, Medicare would pay for almost all diagnosis codes and conditions. As the Federal government seeks to save money the intermediary Novitas Solutions has made changes to policy and has left the providers in the middle. Medicare states they have notified their beneficiaries by the yearly notice that "Not all services are covered by Medicare".

ALL claims are not only based on medical necessity, but reasonableness of the service as well. Medicare states in their policy that a service is only covered if furnished to a beneficiary whose medical condition at the time of the service was such that transportation by any other means would endanger the health or welfare of the patient. The medical necessity goes on the condition of the patient at the time of transport regardless of the patient's diagnosis. To be deemed medically necessary for payment, the patient MUST require both the transportation and the level of service provided. Transport must be to the closest appropriate facility regardless of patient preference. If a patient can walk to the ambulance, then the claim is excluded as Medicare feels if you can walk to the ambulance, you can walk and get into a private vehicle to be transported.

For a routine ambulance transport, ALL 3 of the following criteria must be met:

  1. Unable to get up from bed without assistance.
  2. Unable to ambulate.
  3. Unable to sit in a chair (including a wheelchair).

If a patient can do any of the above, the service is excluded. This is also based on the diagnosis at the time of the transport. Medical necessity is required and it does not allow transport for comfort measures or based on a need to have the patient transported to free up a bed for another patient by a facility. These are very stringent and very few of routine services have been approved by Medicare even with a form completed by the hospital, physician, nurse and/or discharge planner.

Patients who are subscribers to Manheim Township Ambulance Association are given a reduced rate should a service be denied for medical necessity. Those with a Medicare or Medicare Advantage plan are charged what would have been paid by the carrier plus a small fee for the added paperwork and filing with redetermination requests. All non-subscribers are charged the total amount submitted to the original carrier in full. Private health carriers are processed differently.

Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of closest appropriate facilities and are provided by an ambulance service that is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

Medicare does not cover the following services:

REQUESTS FOR MEDICARE APPEALS
With the changes which took place in April 2012 and which have continued through today, there are many services with which Medicare does not deem as Medically Necessary. That being said, they are not saying you do not need services, just the method with which you receive this service. The following statement is direct from the website from CMS:

“ The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

  • Place the patient’s health in serious jeopardy.
  • Cause serious impairment to bodily functions.
  • Cause serious dysfunction of any body organ or part. ”

People with questions on services covered under a Medicare program can get information on the web at (http://www.medicare.gov) which is the website for beneficiaries, families, and caregivers or by calling 1-800- Medicare (633-4227). If you have an Advantage Plan you must then go to the website for your particular plan as these plans differ from what traditional Medicare pays for and they have different coverage policies. Telephone numbers for these plans should also be on the reverse side of your insurance card.

As a provider of services, we only have 1 year from the original date of service with which to submit a claim to Medicare. This is why we need to make sure all information for the beneficiary is correct so a claim can be submitted in a timely fashion. If a claim is denied for medical necessity, there are time limits for the patient to file an appeal as well and this needs to be within the year time frame as well.

First level of appeals is submitted to your local Medicare Administrative Contractor which for us in Pennsylvania is Novitas-Solutions, Inc.. The patient has 120 days with which to file this appeal. The forms can be obtained by visiting Medicare.gov for submission. This will also tell you where to send the appeal.

Second level of appeals is for reconsideration should you receive a denial on your first appeal. The patient has 180 days with which to file this appeal which will be submitted to an independent contractor which for us goes to a contractor in Florida. This form will be the last page you receive on the denial from your first appeal.

The third level of appeals goes to an (ALJ) Administrative Law Judge Hearing. This time frame for appeal is 60 days from the time of denial on the reconsideration. The amount in question must be greater than $150.00 for the appeal to be valid.

The fourth level of appeals is to the Medicare Appeals Council of the Departmental Appeals Board of Medicare. The time frame for this appeal is 60 days from the denial of the ALJ.

The Fifth and FINAL appeal is through a Judicial Review in Federal District Court. The time frame on this appeal is 60 days from the time of the last denial. The amount in question must be greater than $1500.00 for the claim to be valid to go to this level.

We ALWAYS recommend that ALL information submitted on any claim level be copied and a record be kept by the patient or representative thereof. We also recommend that you send the information Certified Mail, Return Receipt Requested so you can verify that your information was received. This assists you in the event Medicare says they never received it, you can then provide proof of receipt.

Information required will be copies of the ambulance PCR which can be obtained through our office. If you do not obtain this, Medicare will submit a request for us to submit it to them. You will need a copy of the hospital admissions notes, nursing notes, and physician’s notes to submit with your request for appeal. Medicare has already received a lot of this information but it helps if you submit as well.

It is found that if you are not admitted to the hospital the chances of winning on appeal greatly diminishes. IF you are admitted it may be for a different reason that what you were transported for. The hospital and physicians’ get paid on a different basis than the ambulance services. A large number of diagnoses have been eliminated for ambulance coverage. It is believed in a number of cases we did nothing to improve your care but only provided a transport which Medicare says could have been done by other means, whether it was available or not.

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