New to Medicare - Figuring out Costs in Advance

[travelover]

I've been on Medicare for about 9 months, but only now have started to use it, recently for my "welcome to Medicare" exam with a GP. The general practitioner charged $560 for the "welcome to Medicare" visit but accepted Medicare's considerably lower reimbursement as full payment.

I'm due for a colonoscopy soon and think I need to ask the right questions before the procedure to ensure unexpected charges. I have Supplemental B coverage F / High Deductible.

Any tips for navigating the expected out of pocket charges before services are rendered?

 

[Katsmeow]

Make sure the provider takes Medicare Assignment. Also check that Medicare will cover the procedure. That is, Medicare will do certain procedures every X amount of time and won't cover it if you don't fit within those guidelines.

DH has been on Medicare for 5 years. Basically everything has been covered (he has regular Plan F) without issue. The main things not covered are things we knew weren't covered -- vision coverage, glasses (although his macular degeneration exams are covered). He takes some supplements for macular degeneration that are not covered. He doesn't taken any medications so that hasn't been an issue.

 

[harllee]

I have had a terrible time with Medicare (see my thread "Medicare Problems"). I have had to pay large sums out of pocket that I thought were going to be covered by Medicare. I don't know how to tell if things will be covered. Talking to Medicare has not helped. I don't know how it is possible to find out ahead of time what Medicare will cover and what the will not cover. I only use doctors that take Medicare but Medicare still rejects my claims. Medicare is costing me ALOT more than I budgeted for. I am pretty disgusted with Medicare myself but I don't know of any good alternatives.

 

[MichaelB]

Make sure the provider takes Medicare Assignment. Also check that Medicare will cover the procedure. That is, Medicare will do certain procedures every X amount of time and won't cover it if you don't fit within those guidelines.

These are the top two most important actions you can take to minimize billing issues and costs to you.

 

[aja8888]

Make sure the anesthesiologist accepts Medicare also.

Some don't and they will send you a big bill. They may be part of a subcontracted group and not in the Dr's or locations network.

 

[bmcgonig]

Make sure the anesthesiologist accepts Medicare also.

Some don't and they will send you a big bill. They may be part of a subcontracted group and not in the Dr's or locations network.

How do you verify that? Do they even know what anesthesiologist will be working on you that particular day?

 

[aja8888]

How do you verify that? Do they even know what anesthesiologist will be working on you that particular day?

Before you go in for surgery, ask the facility who (which provider) is administering anesthesia at their location. Then call them and verify coverage.

Believe me, 10 years on Medicare and several surgeries for DW and myself have made us very careful and not ashamed to find out who covers what.

 

[MichaelB]

How do you verify that? Do they even know what anesthesiologist will be working on you that particular day?

When I had my cataracts done I asked the anesthesiologist when he walked into the room.

 

[harllee]

But if it is an emergency (for example we thought my DH was having a stroke and I took him to the ER) you cannot take the time to call Medicare and find out if a test is covered. If you think it is life and death you just let the doctors run their tests. Then you find out later Medicare will not pay and you are stuck paying a big bill. Not a good system.

 

[mamadogmamacat]

When I had my cataracts done I asked the anesthesiologist when he walked into the room.

I'm not on medicare yet, and who knows what it will be like in about 8 yrs when I am, but have been curious about this. What did he say, and if the answer was "no", or more likely "I don't know, ask my billing dept, would you have canceled what was in this case a somewhat elective, at least in terms of its timing, procedure, and then tried to hunt up a surgeon/anesthesiologist combo (I assume surgeons like to work with other drs of their choosing only) that did take medicare assignment, or what?

 

[aja8888]

But if it is an emergency (for example we thought my DH was having a stroke and I took him to the ER) you cannot take the time to call Medicare and find out if a test is covered. If you think it is life and death you just let the doctors run their tests. Then you find out later Medicare will not pay and you are stuck paying a big bill. Not a good system.

No it's not a good system, but it's all we have. One thing we did, since DW had been brought to ER on several occasions, was to use a hospital that accepted Medicare in ER. Fortunately, one is one mile from our house (St. Lukes). We elected NOT to use the new emergency clinics that had been springing up around us like a field of daisies, most of which did not accept Medicare.

From what we have experienced, all the doctors at St. Lukes are in their "system" and take Medicare. We have never had a problem with any medical tests done either.

The bottom line is you have to be diligent in making medical decisions when on Medicare.

 

[MichaelB]

I'm not on medicare yet, and who knows what it will be like in about 8 yrs when I am, but have been curious about this. What did he say, and if the answer was "no", or more likely "I don't know, ask my billing dept, would you have canceled what was in this case a somewhat elective, at least in terms of its timing, procedure, and then tried to hunt up a surgeon/anesthesiologist combo (I assume surgeons like to work with other drs of their choosing only) that did take medicare assignment, or what?

He smiled, shook my hand and said "I'm a salaried employee with the hospital and if they take your insurance, you're covered".

No it's not a good system, but it's all we have.
./.
The bottom line is you have to be diligent in making medical decisions when on Medicare.

Yes, and it really is a shame.

 

[harllee]

No it's not a good system, but it's all we have. One thing we did, since DW had been brought to ER on several occasions, was to use a hospital that accepted Medicare in ER. Fortunately, one is one mile from our house (St. Lukes). We elected NOT to use the new emergency clinics that had been springing up around us like a field of daisies, most of which did not accept Medicare.

From what we have experienced, all the doctors at St. Lukes are in their "system" and take Medicare. We have never had a problem with any medical tests done either.

The bottom line is you have to be diligent in making medical decisions when on Medicare.

The hospital we went to when I thought my DH was having a stroke does take Medicare. All the hospital/doctor bills have been paid by Medicare. The thing that was not paid was lab blood work. The hospital lab does take Medicare. The reason Medicare will not pay for the lab work ($800) is that they say it was not "medically necessary." The hospital says it was the standard test used for strokes, etc and they don't know why Medicare won't pay, Medicare has always paid this in the past. We called Medicare and they would not answer our question regarding why it was not paid, just that it was not "medically necessary". Maybe it was a coding problem but how is a person suppose to know what the correct code is? No one will tell us. Very frustrating!

You say that we should have been diligent but what was I to do when i thought my husband had a stroke and rushed him to a the closest emergency room in a hospital that I knew did take Medicare. What else could I have done?

 

[mamadogmamacat]

He smiled, shook my hand and said "I'm a salaried employee with the hospital and if they take your insurance, you're covered".

Lucky you. Glad that was the answer. My question remains, however.

Had this problem once already, with insurance while employed. The ER visit was covered, except for the ER Dr himself, who turned out to be an independence contractor.
I had no idea I needed to ask, and not sure if there was another Dr available who was not also an independent anyway.

His bill was only $200. at the time, but my mega corp insurance would pay none of it until I got his office, and my ins and me on a three way call wherein I kept explaining I had no other choice of dr at the time and was not given notice he was not a hospital employee. Eventually, my ins decided to pay the $200., but it was a hassle indeed. Expect Medicare will not be so flexible and i would be out the $200. (or more since that was almost 10 yrs ago, and inflation in medical costs is quite high.....)

 

[aja8888]

The hospital we went to when I thought my DH was having a stroke does take Medicare. All the hospital/doctor bills have been paid by Medicare. The thing that was not paid was lab blood work. The hospital lab does take Medicare. The reason Medicare will not pay for the lab work ($800) is that they say it was not "medically necessary." The hospital says it was the standard test used for strokes, etc and they don't know why Medicare won't pay, Medicare has always paid this in the past. We called Medicare and they would not answer our question regarding why it was not paid, just that it was not "medically necessary". Maybe it was a coding problem but how is a person suppose to know what the correct code is? No one will tell us. Very frustrating!

You say that we should have been diligent but what was I to do when i thought my husband had a stroke and rushed him to a the closest emergency room in a hospital that I knew did take Medicare. What else could I have done?

I understand your frustration and stuff like you experienced does happen, and not just to you.

A few years ago, my Medicare deductible was overpaid by $20 and my Medigap company sent me a letter saying they would not process any new claims until "I" fixed the issue. It took ME 6 months to fix a $20 coding issue with no help from Medicare, Medigap and even the doctor. I ended up finding the billing people (in India) and finally spoke to the right person and got the coding fixed. PIA for sure.

On a good note, I have had a hip replacement, DW has had back surgery, heart valve replaced and has COPD with full O2 24 hours a day. Medicare has paid many thousands of dollars and not missed a beat except for the $20 issue I struggled with a few years ago. We file almost no paperwork and just pay the medigap premiums quarterly.

What I would recommend is that you file an appeal with Medicare on the $800 issue and see how it sorts out. That's really all you can do right now.

 

[MichaelB]

Lucky you. Glad that was the answer. My question remains, however.

We have few options. The suggestions Katsmeow made in post #2 are still the best. Due diligence before the service is provided will not assure us it cannot happen, but it does reduce the likelihood of getting billed from an out of network provider.

 

[mamadogmamacat]

Thanks
pretty much the expected answer

will be interesting to see if/how medicare evolves once all us boomers are eligible

 

[athena53]

I'm not on medicare yet, and who knows what it will be like in about 8 yrs when I am, but have been curious about this. What did he say, and if the answer was "no", or more likely "I don't know, ask my billing dept, would you have canceled what was in this case a somewhat elective, at least in terms of its timing, procedure, and then tried to hunt up a surgeon/anesthesiologist combo (I assume surgeons like to work with other drs of their choosing only) that did take medicare assignment, or what?

Related horror story but not Medicare: a couple who had planned to use The Valley Hospital in Ridgewood, NJ determined that their doc and the hospital itself were in their insurance network. Wife went into labor early and she had an emergency C-section. The anaesthesiology "department", it turned out, was a physician's group NOT in their network. They ended up with a bill somewhere between $2,000-$3,000. The couple went to court over it on principle- and lost.

It's scary out there.

 

[Katsmeow]

The hospital we went to when I thought my DH was having a stroke does take Medicare. All the hospital/doctor bills have been paid by Medicare. The thing that was not paid was lab blood work. The hospital lab does take Medicare. The reason Medicare will not pay for the lab work ($800) is that they say it was not "medically necessary." The hospital says it was the standard test used for strokes, etc and they don't know why Medicare won't pay, Medicare has always paid this in the past. We called Medicare and they would not answer our question regarding why it was not paid, just that it was not "medically necessary". Maybe it was a coding problem but how is a person suppose to know what the correct code is? No one will tell us. Very frustrating!

I know you said the hospital has billed him for it. But what do the statements from Medicare say? We get 2 statements. Medicare does one that says what Medicare will pay and if Medicare has denied anything it will say why. Then it will show how much the patient is responsible for. Most of that will usually be covered by the supplement. Sometimes Medicare will deny a charge and its statement will say you can't be billed for it. For example, awhile back DH's doctor turned in a charge of $574 for shaving a skin growth. The same day the doctor turned in a charge of $194 for destruction of a skin growth. Medicare didn't approve the charge for the skin grown and the medicare statement clearly said DH couldn't be billed for it.

So in your DH's case - what does his Medicare statement say. There should be column that says Service Approved and should have Yes or No. Then there is a column that says Maximum You May Be Billed. For the $574 above, Medicare said NO under Service Approved and under Maximum You May be Billed said $0. So I would look there first to see what the Medicare statement says. That is does Medicare say your husband can be billed for the amount?

(Typically DH then also gets an EOB from the supplement carrier. This is where the supplement carrier pays it share of approved services.)

 

[harllee]

DH's Medicare EOB statement says that Medicare will not pay any of the $800 lab bill and that DH can be billed for $800. DH's Medicare Supplement will not pay any of the $800 since Medicare did not pay any of it. DH has received a bill for the labs for $800.

DH called Medicare (twice) and was told it was not approved because not "medically necessary." DH asked why, told Medicare his situation--in hospital ER because of stroke symptoms, etc. The person on the line at Medicare did not answer the question of why the labs were not considered medically necessary. There was just silence on the line when DH asked the question.

DH will probably file a written Medicare appeal but that is probably a waste of time. I personally have filed 2 Medicare written appeals (one 4 months ago) and have heard nothing at all from the appeals. When I called Medicare about my appeal they tell me they cannot tell me anything because the appeal is handled by and independent contractor. A mess.

 

[MichaelB]

OP here DH's Medicare EOB statement says that Medicare will not pay any of the $800 lab bill and that DH can be billed for $800. DH's Medicare Supplement will not pay any of the $800 since Medicare did not pay any of it. DH has received a bill for the labs for $800.

DH called Medicare (twice) and was told it was not approved because not "medically necessary." DH asked why, told Medicare his situation--in hospital ER because of stroke symptoms, etc. The person on the line at Medicare did not answer the question of why the labs were not considered medically necessary. There was just silence on the line when DH asked the question.

DH will probably file a written Medicare appeal but that is probably a waste of time. I personally have filed 2 Medicare written appeals (one 4 months ago) and have heard nothing at all from the appeals. When I called Medicare about my appeal they tell me they cannot tell me anything because the appeal is handled by and independent contractor. A mess.

Were you thinking about this thread ? http://www.early-retirement.org/forums/f38/medicare-problems-91965.html#post2050071

 

[harllee]

Thanks Michael B, Yes I was thinking of the other thread where I am the OP, sorry. I am not the OP here but I was answering a question on this thread. I do want posters to know that when planning for Medicare coverage it is my experience that Medicare does not cover many medical expenses. i have been surprised how much DH and I have to pay our of pocket even though we have Medicare and a supplement (thousands). I have found that the Medicare employees are not helpful at all.

 

[MichaelB]

Thanks Michael B, Yes I was thinking of the other thread where I am the OP, sorry. I am not the OP here but I was answering a question on this thread. I do want posters to know that when planning for Medicare coverage it is my experience that Medicare does not cover many medical expenses. i have been surprised how much DH and I have to pay our of pocket even though we have Medicare and a supplement (thousands). I have found that the Medicare employees are not helpful at all.

Just to avoid confusion I edited out that part. I think you've done a good job of letting others know of your travails with Medicare. Hope you are able to resolve them them in your favor.

 

[Blueskies123]

An $800 blood lab charge seems way too high. Even if you have to pay it in the end I bet you can ask for cash payer prices or whatever the reimbursement rate is for medicare and it might come down to $150 or less.

 

[CRLLS]

An $800 blood lab charge seems way too high. Even if you have to pay it in the end I bet you can ask for cash payer prices or whatever the reimbursement rate is for medicare and it might come down to $150 or less.

I hear all the complaints. And they are valid. But the issues is with our medical system. Not Medicare. All the issues existed will under mega corp's plan, private plans and ACA. One must see if the Dr, facility and procedures are covered, whenever possible. In emergencies we are left to fate.