Medicare

Medicare pays for much of a patient's health care — but not all of it. Your out-of-pocket expenses depend on whether your doctor or supplier of health-care equipment and supplies agrees to "accept assignment" (the Medicare approved payment amount).

Medicare Basics at Mayo

While Mayo Clinic provides medical services to Medicare patients, Mayo has chosen to be nonparticipating and thus does not accept assignment from Medicare for professional and physician services. By not accepting assignment, it means that Mayo does not accept the Medicare approved payment amount as full payment. Mayo follows an established fee schedule based on the federal guidelines for Medicare patients allowing health-care organizations to charge up to 15 percent above the Medicare allowable for which you are financially responsible.

This is how it will affect you:

*The secondary insurance reimbursement may vary depending on the patient's Medigap policy. Some policies may cover additional charges than in the example. For more information, please visit the Medicare Web site to review the publication titled Choosing a Medigap Policy.

Are there services for which Mayo Clinic must accept assignment from Medicare?
Yes. Those services are:

• Mayo Clinic Hospital facility charges
  Example: Room and board, operating room, some drugs
• Laboratory tests covered by Medicare
• Physician Assistant services
• Nurse Anesthetist services
• Ambulatory Surgery Center charges

How can I tell if Medicare assignment was accepted for a particular claim?
Each of your Medicare Summary Notices will indicate whether Medicare assignment was accepted (assigned claims) or not accepted (unassigned claims).

Is there a difference in the way the assigned and unassigned claims are processed by Medicare?
Yes. Some of the differences are:

Example
Assigned Claims

1. Medicare pays Mayo directly for assigned claims.
2. Mayo receives a copy of the Medicare Summary Notice.

Unassigned Claims

1. Medicare pays the patient directly for unassigned claims.
2. Mayo does not receive a copy of the Medicare Summary Notice.
3. Patients are responsible for forwarding any Medicare and insurance company payments to Mayo.

Are there services for which Medicare will not pay?
Medicare pays for much of a patient's health care – but not all of it. Your out-of-pocket expenses depend on several factors such as the type of service, diagnosis, frequency of service, etc. There are certain types of services for which Medicare does not pay such as regular dental care and regular eye exams. Medicare may or may not pay for services or procedures that it considers routine or preventive. An example of a non-covered service is the routine or preventive component of your annual visit to your primary care physician. Coverage for some preventive services may vary based on frequency of service. Please refer to the federal government's publication, Medicare & You, for a more detailed description of this topic.

There are other specific instances in which Medicare may deny payment. In such a case, what is called an Advance Beneficiary Notice (ABN) form will be required. An ABN is a written notice that you may receive from physicians, providers or suppliers that notifies you, in advance, of any service Medicare may not consider covered. The ABN will tell you:

• that Medicare will probably deny payment for that specific service or item in your particular case
• the reason the physician, provider or supplier anticipates that Medicare will deny payment
• that you will be personally responsible for the full payment of the bill if Medicare denies payment.

An ABN also gives you the opportunity to refuse to receive the service or item.

What to Expect from Mayo Clinic Billing

• Mayo automatically bills Medicare for services you receive.
• Medicare sends you the payment and Medicare Summary Notice for Mayo unassigned services.
• In cases where Medicare and your secondary insurance company have established a contract to accept crossovers, Medicare automatically forwards the MSN to your secondary insurance company. The "Notes Section" of your MSN will read, "This information is being sent to your private insurer(s)." For all others, Mayo will automatically bill the secondary insurance if you have provided Mayo with this insurance information at Registration.
• Mayo sends you an Itemized Statement of Charges after each visit. The charges are listed on the Itemized Statement of Charges only once. The Monthly Statement of Account that follows will reflect a balance forward and subsequent activity.
• Mayo sends you a Monthly Statement of Account and expects payment of "Current Amount Due" from you upon receipt of the statement.
• Upon receipt of the Medicare and secondary insurance company checks, we recommend that you deposit those checks into your checking account and issue a payment to Mayo. Include the lower portion of the first page of your statement with this payment.
• A Monthly Statement of Account will be sent to you each month there is a "Current Amount Due."

Denials or Disagreements with Medicare Reimbursement

• If a charge is denied by Medicare and your Medicare Summary Notice states that you are not responsible for the charge, please call Mayo Clinic for adjustment or resubmission of the claim at 480-301-7033, or
  800-603-0558 (toll-free) if you are calling outside the Phoenix metropolitan area. You can also write to us at Insurance Unit, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ 85269. Please include a copy of the Medicare Summary Notice referring to the denied charge.
• To appeal a denied charge when Medicare states you are responsible for the charge, follow the instructions under "Appeals Information" on the last page of your Medicare Summary Notice. You can also reach Medicare by phone at 800-633-4227 (toll-free). Appeals must be filed within six months of the date of the notice. As a non-participating provider with Medicare, Mayo is not permitted to initiate appeals on your behalf in most instances. However, we will assist by providing Medicare or other insurers with any information requested in reviewing your case.
• When Medicare states that you are responsible for the denied charge, please be aware that Mayo expects payment from you and will continue to send you a monthly statement until your account is paid in full.

Medicare as Secondary Payer
Sometimes, patients designate Medicare as their secondary insurance company. In this case, copies of the primary insurance company's Explanation of Benefits (EOB) and any payments you receive should be sent to the attention of the Insurance Unit, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ 85259. Mayo may choose to accept the amount paid by the primary insurance company as payment in full or will submit claims for the balance to Medicare.

Medicare Advantage Plans
Medicare Advantage Plans are plans offered by private companies that contract with Medicare to provide patients with all their Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. There are various types of Medicare Advantage Plans, including HMO, PPO and Private Fee-for-Service plans.

Effective January 1, 2009, Mayo Clinic in Arizona will only see patients with Medicare Advantage Plans that are contracted with Mayo Clinic Arizona. Mayo Clinic does not agree to the Terms and Conditions, due to the administrative and financial challenges associated with non-contracted Medicare Advantage Plans. We recommend you contact your insurance plan to obtain a list of in-network providers.

Laboratory Billing
Medicare is automatically billed for services that are rendered to you by the laboratory performing your testing.

Many laboratory tests can be performed on a single blood draw or sample collection. Most laboratory testing on samples drawn at Mayo is performed on site. If you have a specialized test ordered by your physician, your sample may be sent to a reference laboratory that is outside of Arizona. If you have a specialized laboratory test performed outside of Arizona, you may receive more than one Medicare Summary Notice and more than one Itemized Statement of Charges. Mayo Medical Laboratories in Rochester, Minnesota is a specialized laboratory commonly used by all Mayo sites.

For questions about charges billed under Mayo Medical Laboratories, please call 800-447-6424 (toll-free). You may also send correspondence to P. O. Box 4100, Rochester, MN 55903.

Additional Medicare Information
If you have not received the federal government's annual publication, Medicare & You, call 800-633-4227 (toll-free) to obtain a copy.

Additional information is available at the Medicare Web site, www.medicare.gov.

For questions regarding your Medicare Part B claims for services that you incurred in the state of Arizona, call
800-633-4227 (toll-free).