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Medicare Billing Question
Old 04-11-2009, 01:42 PM   #1
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Medicare Billing Question

Got my Medicare Summary Notice which summarizes recent Medicare activity
(3 mos?). One of the charges was denied w/ the following footnotes:
a) service being denied because payment has already been made for similar
service within set time frame (I interpret that as meaning this is an every 12 mos procedure--from the Medicare Handbook---and that I violated this since my annual physical last yr was in Nov but it was Dec the previous yr).
b)you should not be billed for this service. You are only responsible for any deductible /coinsurance amounts listed in the "you may be billed" column
(which is 0.00)
c)It appears that you did not know that we would not pay for this service so you are not liable. Do not pay provider for this service. If you have already
paid provider, submit to this office 3 things: 1)copy of this notice 2)provider's bill and 3) proof of payment............

Future services of this type provided to you will be your responsibility.

My question is what that last sentence above means: "of this type"
1) Does this mean that if I violate the every 12 mos. rule in the future( for services where that rule applies) that I will be responsible for that bill? or
2)If I do this particular procedure XXXX in the future, I will be responsible for the bill regardless of whether I violate the 12 mo. rule or not? or
3) I will be responsible for the bill if I do procedure XXXXX and violate the
12 mo. rule?

Apparently the regular 24x7 phone reps didn't know the answer so the case was referred to the Advance Research Group who does not work extended hours and is a "Don't call us, We'll call you" type of group. They did call back within 48hrs as promised and, of course, I wasn't there. They will make another call and , if unsuccessful, do a snail mail run. My understanding is that I will be reimbursed for payment that I made if I submit the documents requested but,
if case 2) above is true, I might not want to be reimbursed. If case 2) is not true, then I would want reimbursement. There is a deadline for submitting documents that is looming so I would want to submit documents soon providing I knew the correct interpretation and consequences.

Anyone have any experience or appropriate links

I talked to a supervisor about how much friendlier a once per calendar yr
rule would be vs the every 12 mos. rule; also how un-customer-friendly
the "Don't call us. We'll call you" policy was when you're under a time deadline but can't sit around the phone waiting for their call. Can't say she was very sympathetic. I think they know there is no competition that can steal their customers away.
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Old 04-11-2009, 01:50 PM   #2
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Originally Posted by kaneohe View Post
... also how un-customer-friendly the "Don't call us. We'll call you" policy was when you're under a time deadline but can't sit around the phone waiting for their call. Can't say she was very sympathetic. I think they know there is no competition that can steal their customers away.
...and that many people have cell phones.
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Old 04-11-2009, 06:35 PM   #3
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Yes, REW, the thought that I might be penalized for being one of these minority holdouts did occur to me as I was writing OP.
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Old 04-11-2009, 06:40 PM   #4
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Originally Posted by kaneohe View Post
Yes, REW, the thought that I might be penalized for being one of these minority holdouts did occur to me as I was writing OP.
Maybe you and Nords should start a club...
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Old 04-11-2009, 11:03 PM   #5
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Maybe you and Nords should start a club...
Surely there are at least 10 posters among the 7000 members who don't own a cell phone...
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Old 04-12-2009, 05:21 PM   #6
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Time for a poll!
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Old 04-12-2009, 08:58 PM   #7
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Quote:
Originally Posted by kaneohe View Post
Got my Medicare Summary Notice which summarizes recent Medicare activity
(3 mos?). One of the charges was denied w/ the following footnotes:
a) service being denied because payment has already been made for similar
service within set time frame (I interpret that as meaning this is an every 12 mos procedure--from the Medicare Handbook---and that I violated this since my annual physical last yr was in Nov but it was Dec the previous yr).
b)you should not be billed for this service. You are only responsible for any deductible /coinsurance amounts listed in the "you may be billed" column
(which is 0.00)
c)It appears that you did not know that we would not pay for this service so you are not liable. Do not pay provider for this service. If you have already
paid provider, submit to this office 3 things: 1)copy of this notice 2)provider's bill and 3) proof of payment............

Future services of this type provided to you will be your responsibility.

My question is what that last sentence above means: "of this type"
1) Does this mean that if I violate the every 12 mos. rule in the future( for services where that rule applies) that I will be responsible for that bill? or
2)If I do this particular procedure XXXX in the future, I will be responsible for the bill regardless of whether I violate the 12 mo. rule or not? or
3) I will be responsible for the bill if I do procedure XXXXX and violate the
12 mo. rule?

Apparently the regular 24x7 phone reps didn't know the answer so the case was referred to the Advance Research Group who does not work extended hours and is a "Don't call us, We'll call you" type of group. They did call back within 48hrs as promised and, of course, I wasn't there. They will make another call and , if unsuccessful, do a snail mail run. My understanding is that I will be reimbursed for payment that I made if I submit the documents requested but,
if case 2) above is true, I might not want to be reimbursed. If case 2) is not true, then I would want reimbursement. There is a deadline for submitting documents that is looming so I would want to submit documents soon providing I knew the correct interpretation and consequences.

Anyone have any experience or appropriate links

I talked to a supervisor about how much friendlier a once per calendar yr
rule would be vs the every 12 mos. rule; also how un-customer-friendly
the "Don't call us. We'll call you" policy was when you're under a time deadline but can't sit around the phone waiting for their call. Can't say she was very sympathetic. I think they know there is no competition that can steal their customers away.
I know the one thing they are real stickey about is the PSA test for Prostate screening. Medicare will only pay for one blood test every 12 months. Period. If you have a PSA test in December, you have to wait until the following December for the next one. There may be an exception to this rule (like prior condition, etc.) but they're are tough on this subject.
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Old 04-13-2009, 09:00 AM   #8
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That was one of them. Another was fecal occult blood test. The 12mo. restriction is listed in the Medicare book for these 2......unfortunately they are each listed separately on different pages so you have to look them up individually. ....and I think you may be right , that preventive and monitoring (an existing condition) treatments may be treated differently....might be all in the coding.
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Old 04-15-2009, 06:14 AM   #9
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Reading several topics on the problems associated with hospitals and insurance companies makes me very thankfull to live in Canada where its all taken care of,certainly its not a perfect system but it sure sounds preferrable to what a lot of Americans have to go through to get health care.
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Old 04-15-2009, 09:55 AM   #10
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Reading several topics on the problems associated with hospitals and insurance companies makes me very thankfull to live in Canada where its all taken care of,certainly its not a perfect system but it sure sounds preferrable to what a lot of Americans have to go through to get health care.
From what I hear, your post should have read "....thankful to live in Canada where is all taken care of EVENTUALLY....". Friends of mine in Canada bitch about having to wait so long for treatment. I, for one, hope we never get the Canadian system in the USA. The price the Canadians are paying is unreal. Everything up there is so expensive. It has to be to pay for their healthcare.
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Old 04-15-2009, 11:48 AM   #11
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From what I hear, your post should have read "....thankful to live in Canada where is all taken care of EVENTUALLY....". Friends of mine in Canada bitch about having to wait so long for treatment. I, for one, hope we never get the Canadian system in the USA. The price the Canadians are paying is unreal. Everything up there is so expensive. It has to be to pay for their healthcare.
I did say it was imperfect and waiting for some services can be an inconvenience but as you say eventually its your turn and everything gets taken care of,for those living in the US and have employer financed health care or have the extra cash to buy into a private plan your system is much more convenient but if you are living on minimum wage or a fixed income or have no job at all or your health risk is so high that no one will insure you then our system makes sense as it takes care of every one irregardless of their financial situation.
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Old 04-20-2009, 11:41 AM   #12
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What makes Jambo's comments so funny, is Kaneho's comments/questions are about government paid health care. If your concerned about our private health care then this really isn't the thread to bring it up. It is a question about government paid health care, not private health care.
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Old 04-20-2009, 04:08 PM   #13
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What makes Jambo's comments so funny, is Kaneho's comments/questions are about government paid health care. If your concerned about our private health care then this really isn't the thread to bring it up. It is a question about government paid health care, not private health care.
I don't know... this type of issue is very similar to what I experience with private health insurance here in the US of A. Forms, paperwork, rules, guidelines, etc. Not as much now that we have a high deductible plan (we just pay the discounted amount), but it still happens. And don't even get me started on dealing with dental insurance.

And it is still difficult for me to schedule a physical with my primary doc in less than one month.
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Old 04-20-2009, 06:15 PM   #14
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How to simplify:
Just get a $15K deductable, like I did, and then, you pay everything, and don't have to even talk to them!

By the way, the premiums are enough lower that you come out ahead after a few years of relative health.

By the by the, It isn't seemingly free, so you don't go unless you have to (unless DW makes you! - never again. $2 grand to have my butt looked up - at least I got the pictures.
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Old 04-20-2009, 08:55 PM   #15
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How to simplify:
Just get a $15K deductable, like I did, and then, you pay everything, and don't have to even talk to them!

By the way, the premiums are enough lower that you come out ahead after a few years of relative health.

By the by the, It isn't seemingly free, so you don't go unless you have to (unless DW makes you! - never again. $2 grand to have my butt looked up - at least I got the pictures.
That's what we have, and it has simplified things. Physicals are covered. Everything else we pay out of pocket. The only issue is labwork that originates during a physical - do we pay or is it part of the physical?

Overall it is simple. Usually $50-90 for a dr visit out of pocket (from basic dr visit to specialist). That compares to $25-50 copay under the "old" insurance. All rx is all on us, but we take measures to get it cheap (mail order rx, walmart $4 generic or $9 generic or 90 days for $10, etc).
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