Do It Yourself Medical Billing
March 18, 2021 4:41 PM   Subscribe

I am a patient with Stage 4 Sarcoma. Standard of care oncology has nothing to offer, but I have been working with an integrative physician and the results have been positive. However, I need to submit invoices to Medicare myself, and need help with coding.

After consulting with several sources about my options for addressing my undifferentiated pleomorphic Sarcoma, I was advised that the primary and best means was surgery. After four surgeries in 2020, three of them post-metastasis, it also became clear that one can only have so many surgeries. The statistics of moving to systemic treatments, i.e. chemotherapy, which is the normal standard of care, did not offer me much in terms of either extension of life or quality of life.

I found an excellent integrative physician, with whom I am most content, but the practice is not set up to bill Medicare. Hence, the burden of submitting the claims falls on me. My assumption is that most medical billers are only set up to work within traditional guidelines, and will not be able to code my treatments properly. I need to ensure that the CPT and J codes are correct and align.

As you can see, I’ve already done a bit of research, but would rather have an opinion or assistance from someone who is experienced and knows how to do this. Most medical billing companies will only deal with practices or physicians. How might I locate some experienced who can help me?

What practices or resources are available for someone in my situation? (I’m willing to pay for the assistance.). I’m hoping to find a biller who works with an integrative patient like myself. I want to ensure my coding is correct, first time final, so I am reimbursed.
posted by onpointe to Health & Fitness (5 answers total) 1 user marked this as a favorite
Maybe you've already been through all this, but this sounds like a very bad idea. I don't think it's at all common for doctors that take Medicare not to do the billing. Your mention that ordinary medical coders can't "properly" code your treatment is a big red flag. It sounds like you are being set up to commit insurance fraud, which as it's dealing with government funds would also be violation of the False Claims Act.
posted by praemunire at 4:55 PM on March 18, 2021 [2 favorites]

Response by poster: It’s a small practice, and they do NOT take Medicare. It’s not that they won’t do the billing; they are just not set up for it. They used to have a medical billing person (individual practice) to whom they referred patients, but since she retired, they have had difficulty finding a replacement. Patients have certainly been reimbursed in the past, so that is not a concern. I don’t want to wait until they find the replacement, so I’m looking elsewhere, or as a last resort, will do the coding myself.
posted by onpointe at 5:02 PM on March 18, 2021 [2 favorites]

Best answer: The physician's office is responsible for providing you with a superbill that has all the CPT codes describing what they did and their corresponding J codes (I assume to describe medications you were given). Did you receive one from them? Even if they are not in network with Medicare or doing billing on behalf of clients they should be able to do that.
Whether Medicare actually covers those services or medications is another story, but I would start by getting that superbill and submitting it and seeing what happens.
posted by zdravo at 5:06 PM on March 18, 2021 [2 favorites]

Best answer: Ditto what zdravo said - the practice is keeping records of services rendered to you, even if the practice does not accept assignment (note that the website says They can't charge you for submitting a claim. If they don't submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.).
posted by ThePinkSuperhero at 5:14 PM on March 18, 2021 [1 favorite]

Best answer: I'm confused. If they don't take Medicare and you are looking to be reimbursed for your out-of-pocket costs, why can't you use the Medicare reimbursement form? You do not need a biller/coder or any information about CPT codes, E/M level, J codes, or anything. All you need is an itemized bill from the practice and a description of the services provided (e.g. a medical note for that day).

Note that non-covered services are never reimbursed by Medicare, and you'd only be reimbursed the Medicare rate for any covered services, not the actual amount you paid.

Apologies if you've ruled this option out before, but it's the only way I know of for an individual patient to get paid by Medicare for services rendered by a physician.
posted by basalganglia at 5:16 PM on March 18, 2021 [9 favorites]

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