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

I have never had a surgery/procedure/visit not covered by Medicare. I always ask my dr if it is covered by Medicare and they have always said yes. My supplement G plan always covers the rest of the cost over what Medicare pays for.

Every year, I look at the different plans (advantage vs supplements) and I will never ever get an advantage plan. If you look at ALL advantage plans at the national level, these insurance companies refuse surgeries/procedures/expert referral visits in the millions every year whereas Medicare doesn’t require referrals or pre-surgery clearances. The advantage plans are so bad that Congress is looking into making huge changes to these advantage plans so they can’t deny services. Get any of the supplements while you can because you might not be able to go to a supplement after being on an advantage plan.

If Medicare doesn't pay, Medicare supplement does pay. It has been that way for years.

Not exactly. With your Plan G, you may be billed for the annual Part B deductible. It isn’t much, $200+, but you will be billed for it by the provider when you use services covered under Part B. I have Plan N, and have some copays along with the Part B deductible. Plan F, which is no longer available to those starting Medicare, includes the Part B deductible, albeit at an incremental premium cost over Plan G that may be in excess of the Part B deductible.

Depends on the supplemental plan. With some supplemental plans, there are some costs that you will be responsible for.

Let them sue you in court, you don't even need a lawyer.

Medical bills no longer go on your credit report.

Worst case scenario is they settle for much less than they were asking.

Abn
 

Health care providers are required to have traditional Medicare patients sign an ABN. Google it.
My understanding is that I they did not the patient is not responsible or the bill

Not true, just the opposite.

Most of that is true except the doctor can check with Medicare before a procedure and they should know if something routine is covered or not! Find a new doctor.

We use Quest Labs for our blood work. The phlebotomist should/could tell you as they are punching in the tests ordered, what is not covered and your responsibility to pay for the test. Then comes the choice to make, refuse it, or do it because it may be needed by your MD. I made a choice a while ago to go ahead and do the test. Quest could not give me an amount for it. My bill for that was $120. Dr's office was surprised by the charge, come to find out, coding error.

I have been a nurse for over 40 years, the last 15 in an office in Jacksonville, AND, I am a medical coder. This is the advice I give EVERYONE.. CALL YOUR INSURANCE COMPANY FIRST! The phone # is on the back of your card. They pay the bill, they know what your particular plan covers. If they say it’s covered & you get a bill, call them back, with bill in hand, & ask if you owe this. Usually you don’t & they will contact the biller. The cause of the problem is most commonly that they used the wrong ICD-10 code to bill with…resubmit with the correct code & like magic…they get paid. I did this for a living & recuperated thousands of $$ for the office I worked for (that they thought they had to write off.) Unfortunately the US government has made this so difficult & such a game, that even the people in a lot of medical offices don’t understand it because they can’t afford to hire the folks with degrees in Health Information Management, like the hospitals can, who know the game & coding in totality. Sad, but a fact of life. Good luck & remember, NEVER pay a medical bill, except your copay, without calling your insurance provider FIRST! (Even the beginning of the year deductible is tracked by your insurance & they can say when you have met it, since the offices don’t have that info.)

If Medicare doesn't cover a doctor ordered procedure, then I question whether the procedure is legitimate or necessary. In addition, if your supplement doesn't cover the cost, the same rationale applies. So, what was the procedure, and what is the doctor's medical specialty?

The doctors know what is covered if not they can code it again and submit it to Medicare. Sounds like you have an Advantage Plan

If you have Government Medicare, the doctors know what's covered and not covered, and they should have informed you. The link someone provided about regarding "Surprise Bills" is the operative issue. They are not allowed. We've had these type bills wiped out before, even with my kids. If you have Medicare Advantage, that is just private insurance with the Medicare name on it, and it has nothing to do with Government Medicare, you have one or the other. In the case of advantage plans, they can be very spotting on what they'll pay us for (I work in oncology). One Advantage plan may pay and the next one won't, even though they're supposed to follow Medicare guidelines. They will usually have things like Local Coverage Determinations (LCDs) for the more expensive procedures. It's not unusual for LCDs to change and not be told until they reject the charge and say, oh there's a new LCD. We always provide an estimated bill, when ask by a patient, although we cannot estimate beyond our own specialty. IMO, go to the Surprise Bill link read it and follow the procedures for your State.

Medicare pre authorization
 

Who is responsible for obtaining preauthorization?

healthcare provider
Who is responsible for obtaining prior authorization? The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider.

Medicare
 

Medicare has an app that when used can tell you what is covered or not covered. It’s
medicare.gov

Check it out from the apple App Store and download it.

Kind Of
 

You are correct, if I understand Florida office processes as they have been shared. In NH and Massachusetts we delivered medical care and billed Primary and Secondary insurances. Our office receptionist team would check qualifications and the patient would be told what and what wouldn’t be covered.

Circumstances can affect this though. Emergency care vs a scheduled choice options change the whole dynamic. Myself, I often wrote off billing if someone didn’t pay for a treatment because it was on us. It worked out in taxes I was told from our accounting staff. I don’t know of a single doctor that would refuse emergency care to save a life.

So many people who are on Medicare plus a supplement believe everything is covered 100% if you have “the best” Medicare plan. That is not true. It is the responsibility of the patient to be sure a procedure,etc is covered. Also, contrary to the belief of these same types of people, not all drs take Medicare. Because you have “the best” Medicare that pays 100%, do your due diligence and be sure Medicare covers it. And before you see a dr, be sure they also take Medicare.

Incorrect. Very few Supplemental plans pay if Medicare denies the service...

Medicare will tell you it's covered, but state that does NOT guarantee payment.

Sooo, once you send in the claim they can (and do) deny the claim...

The amount of incorrect information in this thread is staggering...