Medicare Question

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Specializes in Long Term Facilitly.

When an order is placed through the company pharmacy........does medicare pay the pharmacy directly? And as well as private pay individual with their own insurance company that do not qualify for medicare...is the pharmacy paid directly from the insurance company?

Also, if a patient is covered via medicare............and has a colostomy.........and the facilities colostomy supplies is not what the patient wants to use, does medicare pay for the colostomy supplies?

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Most pharmacies do not bill medicare for anything. The prescription plans that our elderly have now do not belong to medicare, they just work WITH medicare. Things like diabetes supplies, people have to pay cash for and they are not told to bill medicare for reimbursement. People who get their supplies through mail order companies like Liberty have medicare billed for them.

Private insurances: they all pay the pharmacies and we only pay the copays.

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Specializes in LTC, Hospice, Case Management.

Since you list your specialty as long term care... I am going to "assume" you are asking about residents in a LTC facility.. Yes???

If a resident is being covered under medicare, than the facility is paying the contracted pharmacy for all medications ordered for the resident. The facility is being payed by medicare on a perspective payment system - they get a blanket sum of money from medicare based on the MDS RUG scores. For private insurance companies.. they often have a contract agreement with the facility determined before the resident is admitted that works just as medicare. Example: Insurance company states "We will give you $550/day for Mr. X's care". If facility accepts, facility than pays for all medications (including expensive IV ABT's, etc), room/board, therapy, etc

If under medicare and a resident requires something such as colostomy supplies, again, the facility is required to pay for that as well.

Hope this helps

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Specializes in icu, er, transplant, case management, ps.
When an order is placed through the company pharmacy........does medicare pay the pharmacy directly? And as well as private pay individual with their own insurance company that do not qualify for medicare...is the pharmacy paid directly from the insurance company?

Also, if a patient is covered via medicare............and has a colostomy.........and the facilities colostomy supplies is not what the patient wants to use, does medicare pay for the colostomy supplies?

I have Medicare Part D. I had to choose a plan. I had to make sure my pharmacy was willing to bill the plan. I have to pay the deductable of $7, $30, $60 depending on what the drug is and under what tier it falls under. If an individual has his own private insurance, he has to use a pharmacy that is under contract with his insurance. And they will bill him.

I am a diabetic and get my supplies from a supplier who bills directly to Medicare. And bills me for my 20%. If you are under the fee for service type of Medicare, you can use any supplier who has a Medicare billing number. If you belong to one of the HMO Medicare plans or your state pays for your Medicare, you have to use who they tell you.

Woody:balloons:

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Specializes in icu, er, transplant, case management, ps.
Most pharmacies do not bill medicare for anything. The prescription plans that our elderly have now do not belong to medicare, they just work WITH medicare. Things like diabetes supplies, people have to pay cash for and they are not told to bill medicare for reimbursement. People who get their supplies through mail order companies like Liberty have medicare billed for them.

Private insurances: they all pay the pharmacies and we only pay the copays.

I am sorry but you are wrong. Suppliers for respiratory and diabetic supplies do bill Medicare. And if one has Part D, their pharmacy gets authorization from their provider, fills the prescription, you pay your part and the remainder is billed to your plan. I have Humman and I get a statement every month showing what prescriptions they have paid for, my cost and the total amount to date.

Woody:balloons:

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I am sorry but you are wrong. Suppliers for respiratory and diabetic supplies do bill Medicare. And if one has Part D, their pharmacy gets authorization from their provider, fills the prescription, you pay your part and the remainder is billed to your plan. I have Humman and I get a statement every month showing what prescriptions they have paid for, my cost and the total amount to date.

Woody:balloons:

Actually I'm not wrong. Pharmacies will not bill Medicare for supplies, they make the customer pay cash and conveniently do not tell them they can bill Medicare for reimbursement. If you take another look at my post, I said that people with Part D have plans that do not belong to Medicare, they work with Medicare. The plans are for prescription drugs only, they do not cover testing supplies or respiratory supplies. I said supplies, not meds. Insulin and neb meds are covered and billed, testing strips and neb machines are not. To have Medicare billed for supplies, the customer must find a medical supply company who is willing to bill Medicare. I am in home health; one of my jobs is to help get my home care patients on board with companies that will bill Medicare for their supplies.

If it is different in FL where you are, then it's in CA that they do what I have described above.

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Specializes in icu, er, transplant, case management, ps.
Actually I'm not wrong. Pharmacies will not bill Medicare for supplies, they make the customer pay cash and conveniently do not tell them they can bill Medicare for reimbursement. If you take another look at my post, I said that people with Part D have plans that do not belong to Medicare, they work with Medicare. The plans are for prescription drugs only, they do not cover testing supplies or respiratory supplies. I said supplies, not meds. Insulin and neb meds are covered and billed, testing strips and neb machines are not. To have Medicare billed for supplies, the customer must find a medical supply company who is willing to bill Medicare. I am in home health; one of my jobs is to help get my home care patients on board with companies that will bill Medicare for their supplies.

If it is different in FL where you are, then it's in CA that they do what I have described above.

First, if you have Medicare it doesn't make any difference which state you live in. Medicare is a federally funded program that is administer by each state but the state has no say in what it covers and does not cover. Second, you need to reread what I posted. I never said Medicare was billed directly. You obtain your non-durable supplies from suppliers, they bill Medicare. Third, I am a diabetic and I also suffer from asthma. I get my test strips and lancets from Walmarts pharmacy, who does bill Medicare. I also have a neubulizer, as well as the medications used in it. The supplier billed Medicare for my nebulizer and continues to bill my supplies. And for your information, I live in Florida and New York and have needed replacements. Somehow I don't think that I could be that I could live in the only two states that cover and allow billing by suppliers to Medicare.

And I have a problem with you directing people on Medicare to a supplier. I am assuming that you don't push a supplier which your agency has a relationship with or at least I hope you do not. I have been on Medicare since 1991. I research and got all of my own home health agencies and medical suppliers. And so don't most people I know who are eligible. I have gotten a wheelchair, a walker, a elevated toilet seat, all on my own. The only group that can direct, cover or decide not to cover, anything, is HMO Medicare. Something I have stayed away from, so I can continue to make up my own mind.

Woody:balloons:

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First, if you have Medicare it doesn't make any difference which state you live in. Medicare is a federally funded program that is administer by each state but the state has no say in what it covers and does not cover. Second, you need to reread what I posted. I never said Medicare was billed directly. You obtain your non-durable supplies from suppliers, they bill Medicare. Third, I am a diabetic and I also suffer from asthma. I get my test strips and lancets from Walmarts pharmacy, who does bill Medicare. I also have a neubulizer, as well as the medications used in it. The supplier billed Medicare for my nebulizer and continues to bill my supplies. And for your information, I live in Florida and New York and have needed replacements. Somehow I don't think that I could be that I could live in the only two states that cover and allow billing by suppliers to Medicare.

And I have a problem with you directing people on Medicare to a supplier. I am assuming that you don't push a supplier which your agency has a relationship with or at least I hope you do not. I have been on Medicare since 1991. I research and got all of my own home health agencies and medical suppliers. And so don't most people I know who are eligible. I have gotten a wheelchair, a walker, a elevated toilet seat, all on my own. The only group that can direct, cover or decide not to cover, anything, is HMO Medicare. Something I have stayed away from, so I can continue to make up my own mind.

Woody:balloons:

I know Medicare is a federal program. I never said things were not covered by Medicare. Not once did I say that. I said pharmacies do not bill Medicare. Pharmacies in CA do not like to deal with Medicare billing because it is an unbelievable headache. Medicare has rules that private insurance companies do not. The paperwork I have to deal with for my Medicare pts is unbelievable compared to the paperwork the private insurance companies require. When I open a new case and the pt is diabetic or has nebs, I ask where they get their supplies from. If they get them from a pharmacy I ask if they have to pay cash. If they pay cash I ask if they get Medicare reimbursement. I have yet to have a pt not ask me "I can do that?" These people are under the impression, because the pharmacies ask for cash payment, that Medicare does not cover these supplies. The pharmacies are not going to give away their business by directing these people elsewhere.

Part of my job as a home health nurse is to make sure that all my pts have access to all the resources available. Our agency has a working relationship with all the equipment and supply companies in our county. I just start at the top and work my way down the list; some supply diabetic supplies, some carry respiratory supplies, some deal with ADL and mobility stuff, etc. You, as an RN, know enough to research the best way to get your stuff. Most of our elderly do not, partly because they are not aware of what's available and partly because they're too sick to think on their own.

Why am I fighting with you???

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Specializes in icu, er, transplant, case management, ps.
I know Medicare is a federal program. I never said things were not covered by Medicare. Not once did I say that. I said pharmacies do not bill Medicare. Pharmacies in CA do not like to deal with Medicare billing because it is an unbelievable headache. Medicare has rules that private insurance companies do not. The paperwork I have to deal with for my Medicare pts is unbelievable compared to the paperwork the private insurance companies require. When I open a new case and the pt is diabetic or has nebs, I ask where they get their supplies from. If they get them from a pharmacy I ask if they have to pay cash. If they pay cash I ask if they get Medicare reimbursement. I have yet to have a pt not ask me "I can do that?" These people are under the impression, because the pharmacies ask for cash payment, that Medicare does not cover these supplies. The pharmacies are not going to give away their business by directing these people elsewhere.

Part of my job as a home health nurse is to make sure that all my pts have access to all the resources available. Our agency has a working relationship with all the equipment and supply companies in our county. I just start at the top and work my way down the list; some supply diabetic supplies, some carry respiratory supplies, some deal with ADL and mobility stuff, etc. You, as an RN, know enough to research the best way to get your stuff. Most of our elderly do not, partly because they are not aware of what's available and partly because they're too sick to think on their own.

Why am I fighting with you???

I guess your patients are from an uninformed group. Here, in Florida, most of the people are well informed about just what Medicare pays for. Any number of seminars are held each year, a variety of times,to inform people. And if a physician orders something, he generally tells his patients what Medicare covers because he knows that a lot of them live on fixed incomes. And a good number would not purchase things, if they are too expensive.

Are you fighting with me. Well I found your last sentence very condescending. I am 62 years old. And while I am a license nurse, I have found many of my peers to be well informed. And I have been on home care several times in the past 16 years. My home care provider only asked about whatever I was on home care for. And if my diabetes and asthma were causing me any problems and what my blood sugars had been running.

I lived in an independent living residence for eight months. And I found that many of the people there were quite knowledgeable about what Medicare covers and who does the billing. I now live in a house with a roommate. And she is 74 years old. And not a nurse but knows just what her Medicare covers.

You are acting like all old people are just that old and dumb. And not able to handle their own affairs because they are too sick. I am sorry but a good many people who are on Medicare and even when sick, are very capable of handling their own affairs.

Woody:balloons:

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I guess your patients are from an uninformed group. Here, in Florida, most of the people are well informed about just what Medicare pays for.

I guess my pts in CA fried their brains in their surfer-dude days, sorry about that.

And if a physician orders something, he generally tells his patients what Medicare covers because he knows that a lot of them live on fixed incomes. And a good number would not purchase things, if they are too expensive.

The docs don't say anything because they know things are covered. People go to the pharmacies and are told "You have to pay for that yourself." They are not told "You can be reimbursed, we just don't do the paperwork." People out here also will do without other things to buy what they are told is medically necessary to survive. Part of the Fried Brain Syndrome, I guess. I'm so sorry that California does have smart people like Florida does.

My home care provider only asked about whatever I was on home care for.

And I have a problem with that. Have you read the admitting paperwork Medicare requires for homecare pts? It's a head to toe assessment and even asks about if the pt is able to afford certain things. If you aren't being asked that, then your nurses have been negligent.

You are acting like all old people are just that old and dumb. And not able to handle their own affairs because they are too sick.

Once again, you are putting words into my mouth. I never said that and I never implied it. I said "people are too sick to think on their own." That has nothing to do with age, it has to do with present condition. People fresh out of the hospital are tired and stressed, and they often do not think about the simplest things.

Busy Bee, I am so sorry about this. I did not mean for your thread to run away like this.

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Specializes in Long Term Facilitly.

I know how tangled medicare can get, so you guys it's okay. Just don't drop off the deep end.

Someone did answer my question,it is a LTC facilitly. So the facility pays the contracted pharmacy by the funds they receive from medicare, correct? Now say hypothetically, the pharmacy does not get payment for say....4 months. What would be expected? Or do they pay quaterly, monthly, or what? There are rumors going around our facilitly and I am trying to sort the truth from the rumors. Please reply to the question at hand.

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Specializes in icu, er, transplant, case management, ps.
I know how tangled medicare can get, so you guys it's okay. Just don't drop off the deep end.

Someone did answer my question,it is a LTC facilitly. So the facility pays the contracted pharmacy by the funds they receive from medicare, correct? Now say hypothetically, the pharmacy does not get payment for say....4 months. What would be expected? Or do they pay quaterly, monthly, or what? There are rumors going around our facilitly and I am trying to sort the truth from the rumors. Please reply to the question at hand.

I was in a LTC for wound management and rehab. My drug orders were written by a physician who was responsible for me during my stay. The LTC center got them from a local pharmacy. The pharmacy billed Medicare. I do not know how long they waited for payment but I was discharge home before the pharmacy received its first payment.

Woody:balloons:

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