Dr.'s script on Medicare billing rules

John Crudele

Dear John: I'm finding it impossible to understand the Medicare and Medicaid rules regarding a doctor not being allowed to accept payment from these two government groups and then bill me.

I'm not talking about the co-pay.

My doctor accepted payment from the government and now wants me to pay the difference between his normal fee and the amount he accepted, which amounts to $20,000.

The agreement we had was that if he accepted the payment(s) from Medicare and/or Medicaid I wouldn't owe him any money.

The doctor now says he never accepted the government's money. But I have a printout showing he did. Now he wants to sue me.

So here is the question: How do I get Medicare and Medicaid archives to provide me with copies of the payments they made to this doctor? Whom do I write to/go to?

Thanks in advance. B.B.

Dear B.B. Medicare is working on it.

I shared the details of your letter with the government health plan, and an ombudsman has been assigned to your case. Hopefully you've heard from this person by now.

The billing rules for doctors who enroll in the Medicare program are Byzantine. Basically, though, a doctor has the choice of either being enrolled in the program or not. But once a doctor enrolls, he must follow a strict set of rules regarding billing.

Once enrolled, however, a doctor can also choose whether to participate in the plan, or not. Essentially that decision is made annually and will determine how much a doctor gets from the government for certain procedures and how much he can bill the patient -- who Medicare likes to refer to as the "beneficiary."

The amount that can be billed to the patient is the difference between what Medicare pays and what Medicare says the medical procedure should cost. It isn't the difference between what Medicare pays and what the doctor would like to charge.

You didn't give us enough details to determine whether the doctor is doing anything wrong. But, essentially, he could be committing fraud if he is double-billing.

For anyone else having trouble understanding Medicare, call 1-800-Medicare and an ombudsman -- or go-between -- will be assigned to you.

Send your questions to Dear John, The N.Y. Post, 1211 Ave. of the Americas, N.Y., N.Y., 10036, or john.crudele@nypost.com.

medicaid rules, medicare program, billing rules, double billing, government groups, medical procedure, government health, thanks in advance, medicare, health plan, medicaid, ombudsman, beneficiary, fraud, doctors, money
qtdz
Nypost.com