AboutMerry Schiff Expertise I am very familar with Medicare and general insurance questions. I can answer general questions about HMO's.
Experience I have been in the medical billing industry for 50 years. I have helped develop software for this industry. I am a consultant to billers and the medical profession.
Organizations I am the Executive Director of NEBA, a medical billing organization with nearly 1000 members.
Education/Credentials I have been teaching medical billing for many years as well as being a published author with Pearson Education. One book on medical billing (nearly 800 pages) and one on HIPAA.
Question If a patient has a Medicare HMO (ie. humana)that is not contracted with the hospital, is there still some regulation that says they must pay the claim and what they would use was the Medicare FFS (fee for service) rate? Somewhere during the last 18 years i had info that this was so, but am unable to locate it at the moment to find out if this is still the protocol since they invented the new PFFS medicare plans (Private Fee For Service). Any help or reference you can give me would be of help. thanks
Answer The payment would have to be made by the HMO to the hospital if it was a true emergency. They do not have to pay the bill if it were an out of network hospital and not an emergency and emergency is truly a life and death situation. Payments are negotiable if they have to pay.
