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, it 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:

Example

Mayo Clinic charge		$115.00
Medicare approved amount	$100.00
Medicare pays you 80% of approved amount	$ 80.00
Secondary insurance pays 20% of approved amount	$ 20.00
Total paid by Medicare and secondary insurance		$100.00
Patient Responsibility		$15.00

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.
3. Mayo will bill your secondary insurance company if necessary.

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 billing their own secondary insurance company.
4. 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.
• Mayo sends a red-and-white copy of the claim form to you for your secondary insurance company.
• Medicare sends you the payment and Medicare Summary Notice for Mayo services.
• You should match the red-and-white claim form with the Medicare Summary Notice (MSN) and send both to your secondary insurance company. 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)." If you have this crossover plan, you do not have to send the MSN and the red-and-white form to your secondary insurance company.
• 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, you may endorse the back of each check "Pay Only to Mayo Clinic," sign and mail the checks to Mayo. However, we recommend that you deposit those checks into your checking account and issue a payment to Mayo. Please send a copy of your Medicare Summary Notice with your payment if you want the payment applied to the specific charges. You can write your billing account number on the face of the check. This will ensure proper application of your payment.
• A Monthly Statement of Account will be sent to you each month until your bill is paid in full.

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 toll-free 1-800-603-0558 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 toll-free at 1-800-633-4227. 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 replacement insurance plans which replace traditional Medicare. If you have chosen a Medicare Advantage Plan for your insurance, your Medicare is administered by a commercial insurance company.

There are four types of Medicare Advantage Plans:

1. Medicare Advantage Health Maintenance Organization (HMO) Plan
   
   

   Medicare Advantage HMO plans will not pay Mayo Clinic for services without prior authorization. Your physician's referral alone does not necessarily constitute an authorization from your HMO. You will need to receive authorization from your HMO prior to scheduling an appointment. To schedule an appointment you will need to provide Mayo with an authorization number and the service(s) that are authorized (e.g., consults, tests, procedures, treatment, etc.).

   Mayo requests a pre-service deposit for all services that have not been authorized by your insurance. Deposits are based on an estimate of the cost of anticipated services you or your physician request and are not necessarily payment in full. The deposit amount is an average; your actual services may be greater or less than the deposit. If further testing or physician consultations are necessary, additional deposits may be required. If actual costs are less, the balance of the deposit will be refunded.

2. Medicare Advantage Health Maintenance Organization (HMO) with a Point of Service (POS) or out-of-network benefits Plan
   
   

Medicare Advantage HMO with a POS or out-of-network benefits Plans will often allow members to be seen by a physician of their choice. However, members will be responsible for any balance remaining after the plan has paid their portion.

Medicare Advantage HMO with a POS or out-of-network benefits Plans usually pay the majority of a Medicare allowable amount. Mayo Clinic in Arizona is a non-participating Medicare provider. Therefore, the amount Mayo is permitted to charge is 15% above the Medicare allowable amount. You are responsible for any amount not paid by your plan.

3. Medicare Advantage Preferred Provider Organization (PPO) Plan
   
   

Medicare Advantage PPO Plans will often allow members to be seen by a physician of their choice. However, members will be responsible for any balance remaining after the plan has paid their portion.

Medicare Advantage PPO Plans usually pay the majority of a Medicare allowable amount. Mayo Clinic in Arizona is a non-participating Medicare provide. Therefore, the amount Mayo is permitted to charge is 15% above the Medicare allowable amount. You are responsible for any amount not paid by your plan.

4. Medicare Advantage Private Fee for Service (PFFS) Plan
   
   

Medicare Advantage PFFS Plans will often allow members to be seen by a physician of their choice. However, members will be responsible for any balance remaining after the plan has paid their portion. There are some exceptions for those physicians that do not accept the terms and conditions of these plans.

Medicare Advantage PFFS plans usually pay the majority of a Medicare allowable amount. Mayo Clinic in Arizona is a non-participating Medicare provider. Therefore, the amount Mayo is permitted to charge is 15% above the Medicare allowable amount. Patient are responsible for any amount not paid by your plan.

Medicare Advantage PFFS Plan Exceptions

Some Medicare Advantage PFFS Plans (e.g., Medicare Plus Blue PFFS BCBS MI Medicare Advantage PFFS Michigan Public School Employee Retirement System) are exceptions and do not allow non-participating Medicare providers to charge the patient the 15% above the Medicare allowable. The Code of Federal Regulations stipulates that the plan allowed amount must be accepted whenever service is rendered to Medicare Advantage patients – contracted, deemed, or non-contracted; therefore the patient can not sign a "waiver' to be a self-pay patient.

Medicare Advantage Exception patients may be seen for Cosmetic services. Cosmetic services are on a self-pay basis only and are never filed to insurance.

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 Clinic Laboratories, please call toll-free 1-800-447-6424. 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 toll-free 1-800-633-4227 to obtain a copy.

Alternatively, you may visit the Medicare web site at www.medicare.gov to order a copy.

For questions regarding your Medicare Part B claims for services that you incurred in the state of Arizona, call toll-free 1-800-633-4227.