Alta Orthopaedics is seeing all Medicare patients. On January 1, 2002 we made a contractual change with Medicare that effects the fee schedule for the services we provide. This handout explains these changes.

For many years Alta accepted “assignment.” This Medicare term means we agreed to accept the Medicare approved amount as payment in full. This year we have decided not to accept assignment. When a doctor decides not to take assignment, Medicare labels the doctor as a non-participating provider. This is confusing because non-participating providers see and treat Medicare patients. Medicare, on their part, pays a percentage of the billed charges for this care.

A few changes concern you from our decision to not accept assignment:

1. Medicare’s payment for the care you receive is mailed to you, the patient, and not to us. This is a change that can take some getting used to. Alta will bill Medicare for your visit or surgery and Medicare will send you a check for what they allow. Medicare determines what they will pay using a fee schedule for a non-participating provider less the 20% that has always been the patient’s responsibility or the responsibility of a patient’s Supplemental Health Insurance (Medigap) policy, if applicable.

2. Medicare, not the doctor, determines how much doctors can charge. A non-participating provider can charge a slightly higher fee (but it cannot exceed 115% of the fee allowed a non-participating provider). This amount is called the “limiting charge.” The non-participating physician fee schedule is 95% of the Medicare participating fee schedule. The difference between the participating fee schedule and the limiting charge would be an additional 10 to 15 dollars for most follow up office visits. Surgeries may result in an additional cost of 300 to 500 dollars, depending on the complexity of your surgery.

An example might help illustrate the change. Assume you have paid your $100.00 Part B deductible for the year and have no Medigap coverage. Your doctor codes your visit based on the level of complexity. For this example, let us use a common office visit charge of $87.52.

Amount charged	$87.52
Medicare approved amount of $80.11 is reduced by 5% because the doctor is non-participating	$76.10
The most the doctor can accept, 15% more than the Medicare-approved amount ($76.10 x 115% = $87.52)	$87.52
Medicare mails you a check to be used to pay your doctor ($76.10 x 80% = $60.88)	$60.88
You pay the doctor the difference between what Medicare pays and what the doctor is owed ($87.52 - $60.88 = $26.64)	$26.64
What you would have paid if we accepted assignment	$16.02

You paid $10.62 more because of our decision to not accept assignment. You may pay less than this depending on your Supplemental Health Insurance (Medigap) policy, if applicable.

1. Will I have to pay for anything at the time of my visit?
Alta is not collecting your share of the bill at the time of service. You will be mailed a statement notifying you what amount of the bill is your responsibility. We do ask for a $300.00 surgery deposit from those patients who will be having surgery.

2. Will Alta Orthopaedics bill Medicare for me?
Yes, we will bill Medicare for you.

3. What if I have a Supplemental Health Insurance (Medigap) policy?
If your Medigap or supplemental carrier historically has covered the 20% that Medicare does not pay this change to non-assignment will not effect that coverage. Your Medigap or supplement may or may not pay the additional 15% over the Medicare fee schedule that Alta will bill. You may want to check with your secondary carrier regarding your policy benefits.

4. Will I have to bill my Medigap policy?
That depends on your policy. Many supplemental policies “cross over.” This means when Medicare receives your claim they process it and automatically forward the claim to your supplemental policy.

5. What if I have questions about coordination of benefits?
If you have a question about who should pay, or who should pay first, check your insurance policy or coverage. This question usually comes up for the few patients who have more than one health insurance policy. You can call the Medicare Coordination of Benefits contractor at 1-800-999-1118 with questions about who pays first, or how your coverage works with Medicare.