Will the Secondary Pay if Medicare Doesn’t?

May 28, 2018
Rick Gawenda

I often receive questions when a Medicare beneficiary exceeds the therapy cap that go something like this: Currently, I have a patient that has gone over the $2010 or $3000 amount for Medicare. She has not progressed and responded to therapy interventions. She insists that her secondary will pick up the full amount if Medicare denies. I’ve used the GA modifier basically telling Medicare the therapy services are not necessary and had the patient sign an advance beneficiary notice of noncoverage (ABN) form. Will the secondary pay if the Medicare program denies? Does it matter if the secondary insurance is a supplemental insurance or a true secondary insurance?

The answer is

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  1. Oh, I thought that in order to bill the patient,we had to first do an ABN and bill Medicare.
    Could you elaborate a little on how to document and bill a medicare benificiary for cash services that are not covered by Medicare?

    1. For services that are statutorily non-covered by the Medicare program, an ABN is not required and you can bill the Medicare beneficiary cash for those services.

    2. We offer a maintenance program for those patients who have been discharged from PT. Medicare is not billed, and the patient pays for the maintenance program which we design to be similar to their PT program, but manual therapy is not performed.

  2. One our therapists wanted to ask this question: Patient has had two shoulder surgeries & $2010 cap exhausted and now getting close to $3000 mark using KX mod. Is is best to continue in OT using the KX mod and risk the possible targeted medical review after exceeding the $3000? OR could the patient begin PT under the most recent RX under a new eval/POC for PT since they have that cap available in full? Thank you!