Page 14 - Medicare Benefit Policy Manual

(b) Physician Bills the VA; VA Bills Beneficiary for Copayment

If a physician accepts the fee basis card and bills the VA, the VA payment is
considered payment in full. If the VA bills the beneficiary a copayment amount for
authorized physician/supplier services that are covered by Medicare in the absence of
the VA authorization, the A/B MAC (B) pays a secondary benefit to the beneficiary
consisting of the lower of the VA copayment amount or the amount Medicare would
pay in the absence of VA coverage (Medicare allowable amount minus applicable
deductible and coinsurance amounts).

EXAMPLE: A physician accepts fee basis reimbursement for services rendered.
The charges for the services are $96. The VA fee basis rate is $78. The VA pays the
physician $78 and charges the beneficiary a $14 copayment. The beneficiary claims
Medicare reimbursement for the VA copayment amount. The Medicare allowable
amount for the services is $83. The individual’s unmet Part B deductible is $75. The
Medicare secondary benefit is the lower of:

• Amount payable by Medicare in the absence of VA coverage:

$83 - $75 = $8 X .8 = $6.40, or

• Individual’s VA copayment obligation: $14.

The A/B MAC (B) pays $6.40.

The beneficiary’s deductible is credited with $75. If the beneficiary’s Part B
deductible had been met previously, the Medicare secondary payment would be $14,
the lower of:

• $66.40 ($83 X .8), or

• $14.

NOTE: Medicare may pay for covered outpatient emergency services furnished by a
VA hospital if there is a charge for the services. Medicare’s payment is subject to
applicable Part B Medicare deductible and coinsurance provisions. Accordingly,
there is no Medicare payment until the Part B deductible is met. However, any
charges to the beneficiary for covered VA hospital outpatient emergency services are
credited to the Medicare Part B deductible. The CMS, OMB, Division of
Accounting, which is responsible for processing claims for emergency services by
Federal providers, will ensure, in these cases, that pertinent data is entered into the
beneficiary’s Health Insurance Master Beneficiary Record.

5. Procedure

(a) Claim Is for Primary Medicare Benefits