MEDICARE Fact or Fiction?
 

MEDICARE Fact or Fiction?
Is there is no way for a patient to know, in advance, if a 'treatment/prescription/therapy' is/will be covered by their Health Insurance?
Our friend got an unexpected invoice, so I called them for her.
I was told by the doctor, Medicare and the insurer that they cannot tell a patient, in advance, if a proposed medical expense is covered.
Apparently your medical provider submits an invoice to Medicare.
They decide which items they will pay.
Your insurer will only pay those charges which exceed what Medicare paid..
What we didn't realize is that, if Medicare says 'We don't cover that at all.' then your Supplemental Insurance doesn't either.
So, even with the best 'F' Supplement you're stuck with an unexpected expense!
Oh well!

PYour doctor should know if a treatment will be covered by Medicare or your supplement. They most likely have treated a patient in the same manner before you. You should be careful with experimental and cosmetic treatments. Most are not covered by Medicare.

There is an official Medicare website that lists what they do & don't cover. There is a search for test, item or service.
Your Medicare Coverage | Medicare

There is also an app which does the same, you can look up what is covered.
This is the Android version:
What's covered - Apps on Google Play

It is called What's Covered? & it is published by CMS.gov

I have gotten in the habit of asking "Is this covered by Medicare". I have never had a Dr tell me they didn't know. Sometimes it's a "coding" issue and the DR or provider needs to provide additional/better info to Medicare. I have had to badger providers to get items resolved.

I have never run into this. I have United Health Care J Plan and everything is covered. I have never even heard of a doctor doing procedure which was not covered under the patients existing plan. In fact I have been sitting in Dr. Georges (Cardiologist) waiting room and heard the receptionist telling people their insurance will not cover this, this and this. It certainly does not sound very ethical to do a procedure without first informing the patient of the cost to them.

Note that a Medicare supplement policy is not really a stand alone insurance policy. It is a piggyback plan. Basically, it pays for the 20 percent coinsurance that Medicare does not cover. So, if Medicare doesn't cover a treatment, your Medicare supplement will not cover it either.

Whenever I wasn’t sure if a procedure would be covered, I first have a chat with UHC to verify coverage.

The above info is not the norm. Are you sure you are talking Medicare and not Medicare Advantage? Does the Provider accept the Medicare payment schedule? Are you talking about Medical needs as opposed to elective procedures?

There are certain conditions that most providers are aware exist. As an example, consider cataract surgery. Medicare will not pay for the surgery until the cataract reaches a certain maturity. If the provider believes there is a compelling reason to perform prior to that maturity, then a request and justification must be provided.

One simple recent example. My GP requested a blood test prior to a physical. His subscription for the blood test was sent to LabCorp. While getting the blood withdrawn for the requested test, I was presented a form to sign by LabCorp stating that one of the tests may not be paid by Medicare. I opted to get the test assuming it was necessary. Sure enough Medicare did not pay. Long story short, the GP request did not use the proper Medicare Billing code. The correction process is not fun, but it indicates what can happen if the provider is not adept with the billing code system.

You are able to call Medicare and your insurance before any medical procedure or test to find out if it is covered. If your doctor tells you differently run, their office knows what is and was isn’t covered. Sounds like a crooked doctor

Medicare Coverage
 

I once sent a letter to a provider and asked that I be notified in advance of tests and treatments that were not covered. Two weeks later received notice he was dropping me as patient! Had received a $1200 diagnostic bill.

I have Aetna PPO Advantage and never had this problem! My doctor wanted me to have a few pre surgery tests and was able to tell quickly if Medicare/Aetna covered them. She switched the coding on a few and got them covered.

Not surprising. It is a pretty standard practice that medical providers will hold patients responsible for any test or procedure that is not covered by their insurance. You are usually required to sign an agreement that clearly states it. With all of the different insurance policies and requirements, I don't blame them.

sometimes the code that is used for the procedure is wrong on paperwork and that changes everything. Has happened to me and I called my supplemental and Medicare and it was rectified. Worth the time to call

With F coverage unless medicare doesn't cover it - all is paid. Google to find out what is and isn't covered. You can check online with Med D companies to see what drugs are covered and medicare to see what also is covered. And YES a Dr 's office can check and see if something is covered and should know already in most cases. Drugs are a different story as it depends on your Med D plan. They are different. If you don't know how to research these things it is much harder for you.

charge
 

You didn't say what procedure was not covered I suspect it is unusual. Only warning I know is at the hospital make sure you are admitted or it costs more