Quote:
Originally Posted by RARO1
If they did disclose a risk behavior to the DR then as per Medicare’s policy they should have covered it, they will cover 1 test a year for people 16-65, and for people over 65 if they are at an increase risk for hiv.
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Absolutely yes. But it gets a bit tricky. When a MD orders a lab test there are two separate codes. One specifies the lab test being ordered. The other specifies the reason for the test. There are different codes for the reason. One code is used if there is no medical reason for the test, it is just being done as a screening test. If the MD used that code then Medicare should decline to pay per their regulation.
There are several other codes for ordering the test including one for test being done due to increased risk. If one of the parents had told of an at risk behavior that is the code that should have been used and Medicare would have paid. Maybe the MD used a wrong code or he didn't want the at risk code in the record in case the spouse looked at the order form. It gets very tricky. The MD's office staff would have to tell the spouse that the test was routine as it cannot tell the spouse that the other spouse has been involved with at risk behaviors.
If this unlikely scenario is the true one then there are three options. Pay the bill and stay silent, admit to your spouse that the test was done due to a risk event and have the MD re-code the original order, or the at risk spouse can ask the MD to re-code and hope the other spouse never figures out why the bill suddenly got paid.