Page 12 - Medicare Benefit Policy Manual

as certain other veterans who require medical services for an extended period when VA
and other Federal health care facilities are not capable of furnishing economical care, or,
because of geographical inaccessibility, are not capable of furnishing the care or services
required. The card constitutes an agreement by the VA to pay up to a specified monthly
dollar amount for treatment of specific disabilities or for any condition specified on the
face of the card. The veteran is not restricted in choice of physician nor does the
physician selected by the veteran have to inform the VA in advance that they will be
treating the veteran. (The physicians are not participating physicians in the VA program
nor does the VA have an express “assignment” procedure.)

When the charges for the services exceed the specified monthly amount routinely allowed
by the VA, the VA may allow an additional amount if the physician justifies the need for
the additional cost. If justified, the VA will authorize an increase in the monthly dollar
limitation for a specific period of time. The VA may approve charges for services
exceeding the specified monthly amount retroactively if they were of the type that would
have been approved had they been submitted in advance.

2. VA Fee Basis Payment Is Payment in Full

When a physician accepts veterans as patients and bills the VA, the physician must
accept the VA’s “usual and customary” charge determination as payment in full. Neither
the patient nor any other party can be charged an additional amount. Except for the VA
copayment (see subsection 4(b)), Medicare cannot make payment on an assigned or
unassigned basis when the physician’s bill exceeds the amount the VA paid a physician
who has accepted the “Fee Basis” card. However, as indicated in subsection 4(a),
Medicare can pay for services that are not reimbursable by the VA. Therefore, the mere
existence of a “Y” trailer code indicating that the beneficiary has a VA fee card (as
discussed in subsection 5) is not sufficient to deny Medicare benefits. See subsection
4(a) for secondary Medicare benefits where the veteran bills the VA, and the VA
reimburses the beneficiary or physician less than the Medicare allowable amount.

3. Crediting Part B Deductible

Payments made by the VA for otherwise covered services are credited to the
beneficiary’s Part B deductible. (See subsection 5(c).)

4. Secondary Benefits

(a) Veteran Bills the VA

Where the physician does not accept the fee basis card (i.e., bills the veteran directly)
the veteran may file a claim with the VA. The VA may either reimburse the
beneficiary for out-of-pocket costs or pay the physician based on a claim filed by the
beneficiary. If the VA payment to the beneficiary or physician based on a claim filed
by the beneficiary is less than the Medicare fee schedule or allowable amount for the
services, Medicare can pay secondary benefits to supplement the VA payment,