Medicare, CT/MRI Scans, and EEG's

[Another Reader]

Unlike the "lucky" folks I read about here that had COVID and suffered no after effects, I'm a "long haul" patient. I have a number of neurological sequlae that make it impossible to function normally.

I'm also on Medicare and I'm finding that unless you are hospitalized and a stroke is suspected, it's almost impossible to get a neurologist or any other doctor to order any meaningful tests. A brief look at Medicare billing and coding looks like there are few if any relevant diagnoses that support ordering MRI's/CT's or EEG's.

The annoying aspect of this is that the doctors (neurologists) are evasive and say the tests are not really necessary. That's garbage. Younger people with employer or ACA policies and neurological problems are getting these tests. Damage is being detected and treatment offered. So far, I have been offered a sleep study by both Stanford and Sutter/PAMF. Apparently, Medicare pays well for these studies, so there is motivation to offer them.

Can MSBC or someone else familiar with Medicare explain how this works and how to get these tests approved? Are there patient advocates that for a fee will negotiate with the medical bureaucracy to get these tests done?

 

[John Galt III]

My medicare advantage policy would charge me a $300 copay for an MRI. And the medicare advantage plan would kick in an additional small payment, like $45, possibly. Is $345 not enough for the doctors to consider the MRI profitable?

 

[braumeister]

My last MRI was about five years ago. Billed at $705 for the procedure, plus $227 for reading it. Standard Medicare coverage. That was required by an ortho for a hip problem, but an MRI is hardly an unusual procedure.

 

[RetMD21]

Scans aren't always needed. There is a new issue in 2021. Appropriate use criteria. The doc (or staff) has to enter a code when ordering the test and after entering reason for scan ninto software. One more step. Scans aren't being turned down but the physicians are being profiled. https://www.cms.gov/Medicare/Qualit...-Instruments/Appropriate-Use-Criteria-Program Nobody wants to be a high outlier

 

[Another Reader]

Scans aren't always needed. There is a new issue in 2021. Appropriate use criteria. The doc (or staff) has to enter a code when ordering the test and after entering reason for scan ninto software. One more step. Scans aren't being turned down but the physicians are being profiled. https://www.cms.gov/Medicare/Qualit...-Instruments/Appropriate-Use-Criteria-Program Nobody wants to be a high outlier

And this is likely why neither neurologist I saw for my neurological COVID issues would order any additional MRIs. "Original" Medicare is deteriorating into the government equivalent of Medicare Advantage...

 

[youbet]

Since your situation is having a significant negative impact on your life, why not negotiate to pay the Medicare rate and private pay?

 

[Another Reader]

Since your situation is having a significant negative impact on your life, why not negotiate to pay the Medicare rate and private pay?

Told the Stanford neurologist I brought my checkbook. How much? He changed the subject.

It's not that simple. You can't go around Medicare. Wouldn't survive an audit. The providers have to toe the line. I already went through trying to get an EEG through PAMF. Found a diagnosis and a billing code in the Medicare manual. I will get a one hour in-house EEG after that discussion.

ETA: The medical community, at least in Northern California, are becoming Covid deniers. The provider organizations refuse to create Covid care clinics, staffed with knowledgeable doctors. Instead, Covid care is dumped on unprepared PCPs, with no guidance or direction. The PCPs play the referral game, often to uneducated specialists that don't want to deal with Covid. The referrals get kicked back or redirected. Why does this happen? Covid is bad for business. It killed revenue from traditional care in the spring. Provider organizations do not want any association with Covid that can be avoided because it hurts their bottom line.

With 2.73 million cases in California, a 10 percent rate of long Covid is 273,000 people. How long can the "heads in the sand" denials continue? We shall see.

 

[youbet]

Change neurologists

 

[Mark1]

Change neurologists

+1. Also, I wouldn't ask "how much" as this might be interpreted wrong. I would ask is there any entity in the area that provides this service outside of medicare where you can pay for 100% of the cost.

I am curious, what are your hoping to learn out of the test, e.g., that you don't have a blood clot, etc. and indeed are a COVID long hauler? Once you get this confirmation, does your strategy/path forward change? I'm totally ignorant on the subject, but I am very sorry you are going through this.

 

[Bamaman]

My wife has terrible arthritis and has had to go to a neurologist from time to time. We've found that the specialty is extremely difficult to get into as there are relatively few of them. And we've seen that neurologists are not all created equal.

If one doctor is unable to take care of you properly, there's always another out there. Maybe the other doctor is better at working Medicare's protocol for your long list of problems.

My wife is a medical professional (when she worked), and she's very good at working the system. But her foot reconstruction surgery last week was put off indefinitely until the census of Covid patients is lower locally. It's hard to imagine how much hospital revenues are suffering for elective surgeries right now. Of course, they're billing someone for the Covid patients' care to make up for it.

 

[Another Reader]

Change neurologists

There aren't a lot of choices in neurology. I'm not the only person reporting this, either. ALL the major provider organizations are doing it.

 

[Another Reader]

+1. Also, I wouldn't ask "how much" as this might be interpreted wrong. I would ask is there any entity in the area that provides this service outside of medicare where you can pay for 100% of the cost.

I am curious, what are your hoping to learn out of the test, e.g., that you don't have a blood clot, etc. and indeed are a COVID long hauler? Once you get this confirmation, does your strategy/path forward change? I'm totally ignorant on the subject, but I am very sorry you are going through this.

Unfortunately, almost all of the independent neurologist practices have been bought by the big providers.

Numerous patients in the support groups report MRI's with white matter hyperintensities, some in their 20's and 30's. Most are told they are "normal." An interventional cardiologist in Southern California got tired of the gaslighting and got herself accepted in to the Mayo clinic neurology department for a study. They did contrast MRI's on their high Tesla machine and found more detail of white matter hyperintensities and lesions, which they diagnosed as demyelination. She's 44. I suspect that's what I have as well. Treatment is unclear at this point.

 

[youbet]

There aren't a lot of choices in neurology. I'm not the only person reporting this, either. ALL the major provider organizations are doing it.

DW and I walked a similar path. Our son developed symptoms indicating a neurological problem. With much pushing and effort on our part, his case escalated from our GP to several neurologists to a top tier neuro-opthalmologist at Rush Presbyterian who (finally) came up with the diagnosis: Arnold chiari malformation. We were blown off by several generic neurologists along the way when routine tests did not result in a familiar (to them) diagnosis.

The neuro-ophthalmologist pulled strings and got us into the leading neuro-surgeon for Arnold chiari malformation who performed an 8 hour surgery and, long story short, things have worked out fairly well.

My bottom line to you is that you’re going to have to dig hard to find docs who want to pursue diagnosis of the cause of your symptoms. Join studies. Don’t rule out an international search. Don’t let insurance rules stand in your way.

 

[RetMD21]

Probably seeing another neurologist is your best option although not necessarily easy. Maybe overseas.