Medicare Problems

[harllee]

I am 66, DH is 67. When we each turned 65 we signed up for traditional Medicare, a Medicare supplement "G" and a part D policy. We thought that when we made it to 65 and got on Medicare (and ditched our high deductible health insurance policies) we would be in much better shape regarding health insurance. Not so. We have had constant problems with Medicare, doctor screw ups, many calls to Medicare, having to pay for things that should have been paid by Medicare, etc. We have no problem with our Medicare supplement, but the supplement only pays if Medicare pays. Some examples of problems we have had in the past year:

1. I had Medicare under my own SS number initially and then when I started receiving spousal SS in 2017 I got a new Medicare number based on DH's SS number. When I got the new Medicare # I had already paid my $183 Medicare part B deductible for 2017. Medicare made me pay a second $183 deductible for 2017 after I got the new Medicare number. Everyone I have talked to at Medicare says this should not have happened but it did. After numerous calls to Medicare and appeals i just gave up and paid the second $183 deductible to preserve my credit rating.

2. I got a physical in 2017. I told my doctor I wanted the Medicare Annual Wellness visit which Medicare would pay for. Instead I was billed $400 for a regular annual physical for which Medicare will not pay. I have worked diligently with my doctor's office to get the coding on this physical changed so that Medicare will pay but so far no luck. So I guess I am stuck paying $400.

3. I was the victim of Social Security identity theft in early 2018. Someone fraudulently claimed my Social Security and received around $5000. I finally got that stopped and got my spousal social security restarted. When the fraudulent SS claim was stopped my Medicare was also terminated. It took a couple of months to get Medicare reinstated. During that time I got sick and had to pay out of pocket to go to the doctor. So far Medicare has refused to reimburse me.

4. DH has developed a fairly serious medical problem and his doctor order laboratory tests in order to diagnose what the problem is. Medicare has denied the lab bill of $800 and have said the lab test are not "medically necessary." He has been on the phone all day today with Medicare, his doctor and the lab that did the test. His doctor says he has never heard of Medicare denying these particular tests.

I wonder if anyone else is having all these problems with Medicare. I guess I just wanted to rant. Thanks for listening.

 

[REWahoo]

I wonder if anyone else is having all these problems with Medicare.

At the risk of jinxing us, nope, all has been smooth sailing on Medicare for the past 5+ years for both of us.

 

[aja8888]

We have been on Medicare, Plan F, and Part D for 8 years now with only one $20 hiccup years ago. I suggest you pick doctors that know how to work with Medicare.

Also, ALWAYS CHECK with the Doc's and Medicare for coverage for any special tests, lab work, surgery, etc, before going forward. That goes for Plan D meds too.

We have gone thru hip replacment (me), knee surgury (me); COPD, vertebrea compression fractures, heart valve replacement (DW), etc, with no billing/payment issues.

 

[harllee]

OP here, I agree that I probably could have done a better job on my physical to make sure it was covered by Medicare (although I did request the Medicare wellness visit but I didn't get it in writing). But the double deduction I had to pay and the medicare cancellation due to identity theft had nothing to do with my doctors. My husband's situation was an emergency and I was in no position to say is this test covered by Medicare when my husband's life was potentially at stake.

Most of my issues are not a problem with my doctor, they due to the incompetency of the folks at Medicare.

 

[aja8888]

OP here, I agree that I probably could have done a better job on my physical to make sure it was covered by Medicare (although I did request the Medicare wellness visit but I didn't get it in writing). But the double deduction I had to pay and the medicare cancellation due to identity theft had nothing to do with my doctors. My husband's situation was an emergency and I was in no position to say is this test covered by Medicare when my husband's life was potentially at stake.

Most of my issues are not a problem with my doctor, they due to the incompetency of the folks at Medicare.

I understand your situation and I'm sorry to hear about the problems.

On a personal basis, we have found the Medicare folks to be quite good and we probably have called them scores of times. Where we have found issues has been with the medical practices understanding of the Medicare coding and billing process. And we only had one small problem that took some effort to correct.

Maybe we are lucky to be in the Houston, Texas area where we have world class doctors and medical facilities and a population of over 4 million with many folks of Medicare age. I don't know if that makes a difference, but we seem to manage it quite well here.

 

[harllee]

OP here, the worst medicare incompetence I have found was on my SS fraud. SS people say they told Medicare that I was the victim of SS fraud and that my Medicare was not to be terminated. Medicare terminated me anyway. Medicare says it was the fault of SS. I was going round and round in circles with SS/Medicare. I finally called my Congressman and he got it straightened out. My Congressman is investigating because he says there are way too many SS/Medicare fraud cases being reported since the Equifax breach. He thinks the SS/Medicare security is too lax and it is too easy for a crook to fraudulently claim SS and Medicare.

 

[harllee]

Op here, While I am ranting about Medicare--on several occasions I have been promised call backs after speaking to someone at Medicare (the national number) and I never get a call back. One time I could not understand what the Medicare person on the telephone was telling me and I asked for to speak to their supervisor. I was promised a callback by a supervisor, the call back never came. I also filed a written appeal (twice) and never got a response. I don't know if Medicare simply does not have enough employees or that the employees they have are incompetent. The only real help I have gotten was when I got my Congressman's office involved and magically my problem was fixed.

 

[Katsmeow]

For the OP - I understand why you are upset about all this. You have had what I think is an unusual set of problems, particularly on the identity fraud thing.

I remember your thread on the annual wellness visit and it certainly sounded to me like you had done everything correctly. I wouldn't be upset with Medicare on that. I would be upset with my doctor's office and if they wouldn't correct it I would switch to a different doctor.

DH has been on traditional Medicare for 5 years and has had no problems. He has had to have surgery twice and everything was paid except I think one medication that was given at the hospital but would be covered (or not) by his Part D. It was under $50 so he just paid it.

My mother is 94 and has traditional Medicare. She has had very few problems with Medicare. She did have one doctor who always charged her something. For years I couldn't figure out what she meant. Knowing what I know now I think she was going to a doctor who took Medicare but didn't do Medicare assignment. She just didn't understand this.

She has been in the hospital and rehab for most of the last 2 months. She is about to be discharged and I was talking to the home health care provider who said that it was good she was on traditional Medicare. Several times I have had providers mention it favorably when they find out she is on traditional Medicare. I think for most people it goes more smoothly than Medicare Advantage.

 

[harllee]

OP here. How is the best way to make sure things will be covered by Medicare? Should you try to get a statement on writing before hand (may not be possible). In DH's situation about a month ago he woke up with terrible headache and could not see well out of one eye. I immediately thought he was having a stroke so I rushed him to the emergency room. They ran lab tests to try to determine what was happening, finally decided not a stroke. I did not ask whether Medicare would cover the tests. I thought it was possible life threatening. The next day DH went to opthamologist who decided it was either shingles (DH had shingles at least 3 times before even though he had the shingles vaccine) or that it was uveitis caused by his psoriatic arthritis. They are still not sure which but they treated him for both. He never broke out in rash but evidently you can get shingles in your eye without a rash. DH is doing better but still does not have full vision. Anyway, Medicare has rejected payment of $800 for lab work done in ER to determine if DH had a stroke as not "medically necessary." DH has called Medicare and hospital billing. Hospital billing does not understand why rejected, they say Medicare always pays for these type tests. We are trying to get them to resubmit with more information. What else can we do? What else should I have done in the ER to make sure Medicare would pay? I was not going to say don't do the tests when I was concerned that my DH was having a stroke!

 

[athena53]

I'll be interested in the answers to this.

I started on Medicare on 1/1 and had my GYN do my annual wellness visit. That was covered, no problems. I found that most of the $800 bill for lab work had been denied as "not medically necessary"- this included Hba1c (I have borderline high glucose) and the comprehensive lipids panel (I have borderline high cholesterol although most of the components/ratios are very good). They denied the thyroid test as well. I sent a letter to the doctor's office with copies of everything and asked them to handle it, then left the country for 3 weeks on vacation.

I recently got an EOB that showed Medicare paid piddly amounts for most of the tests and I didn't owe anything for the others. No idea if the doc's office did a darn thing but apparently I'm off the hook.

I'd never had these issues with DH, who died in late 2016 of acute myeloid leukemia. Other than some reasonable OOP for prescriptions he was very well- covered by Medicare and the supplement. Are they suddenly tightening up on what's "medically necessary"? I've since learned from the group here that you can buy home tests for a1c and cholesterol OTC at drug stores and may go to those.

My main concern is my next mammogram. My sister (not on Medicare) decided she wanted something more specific than a mammo since our mother died of a recurrence of breast cancer at age 85; her mammograms had been negative. My sister got an MRI (I think). They found a 4 mm cancerous lesion and she had a double mastectomy. She's a doctor so it was an informed decision. Although her test for 33 mutations that might indicate a higher risk of BC all came back negative, the fact is she still got it and I'm at risk with that family history. I'd really like to get the more specific test and don't want to be dinged for thousands of $$$ if Medicare turns it down.

 

[harllee]

OP here, athena, good thought that maybe Medicare is tightening up on what they consider "medically necessary", have not thought of that. Maybe it is a cost saving measure at the expense of the insureds. DH specifically asked Medicare why his tests were not covered and the Medicare person on the phone did not answer him.

Regarding your mammogram question, I do not know the answer, Medicare paid for a regular mammogram for me but I do remember that the mammogram clinic did say I had to wait a full year before I would qualify for another mammogram.

 

[Katsmeow]

They ran lab tests to try to determine what was happening, finally decided not a stroke. I did not ask whether Medicare would cover the tests. I thought it was possible life threatening. The next day DH went to opthamologist who decided it was either shingles (DH had shingles at least 3 times before even though he had the shingles vaccine) or that it was uveitis caused by his psoriatic arthritis. They are still not sure which but they treated him for both. He never broke out in rash but evidently you can get shingles in your eye without a rash. DH is doing better but still does not have full vision. Anyway, Medicare has rejected payment of $800 for lab work done in ER to determine if DH had a stroke as not "medically necessary." DH has called Medicare and hospital billing. Hospital billing does not understand why rejected, they say Medicare always pays for these type tests.

I've never had this happen. DH did have one procedure that his primary care doctor did that Medicare didn't think should be done (I don't recall why). Anyway, it was clear on the EOB that this was between the doctor and Medicare. DH could not be billed for the amount. If Medicare didn't pay then it was the doctor's loss, not DH's. Is the hospital trying to bill your DH? If not, then don't worry about it as it is between the hospital and Medicare.

 

[harllee]

OP here, Yes my husband has received a bill for the $800 lab work. He is trying to get the hospital lab company to send more information to Medicare to prove that the lab work was "medically necessary". Hospital keeps saying that Medicare should have paid this, it has never been denied by Medicare before, that they don't know what else to send Medicare, etc.

Regarding my physical that was incorrectly coded I have told my doctor I might have to leave his practice and go to another doctor over this (although I have not found another local doctor that I want to go to who is accepting new patients and who also accepts Medicare.). My doctor asked me not to leave and said he will get this billing matter straightened out. I hope that is the case since I don't really have another option for a GP.

Has anyone had any success getting reimbursed by Medicare for payments out of pocket that Medicare was suppose to pay? I have filed claims with Medicare for my out of pocket costs for when I was incorrectly charged a double deduction in 2017 and for my out of pocket costs when my Medicare was incorrectly terminated. I was told by Medicare to file these claims. But it has been 3 months for one claim and 6 weeks for the other and I have heard nothing. I have called Medicare and they say these claims are handled by an outside contractor and they cannot do anything.

I think I am doomed using Medicare. I though Medicare would be smooth sailing but it has turned out to be a big hassle and does not pay my medical bills. But I guess living in the U.S. and being over 65 I have no other option. I wonder if a Medicare Advantage plan would be better than traditional Medicare?

 

[athena53]

I've never had this happen. DH did have one procedure that his primary care doctor did that Medicare didn't think should be done (I don't recall why). Anyway, it was clear on the EOB that this was between the doctor and Medicare. DH could not be billed for the amount. If Medicare didn't pay then it was the doctor's loss, not DH's. Is the hospital trying to bill your DH? If not, then don't worry about it as it is between the hospital and Medicare.

I think that's what happened in my case. The lab never billed me and had to eat the costs. I still feel bad. What they get reimbursed is laughable.

The OP asked about Medicare Advantage. There should be less hassle about what is/is not covered - a friend who has it loves it. I avoided it for two reasons. First, it has a very narrow network. Second, if you decide to go back to regular Medicare they don't have to take you (they can "underwrite" you) so it may be a one-way street.

 

[ivinsfan]

I think that's what happened in my case. The lab never billed me and had to eat the costs. I still feel bad. What they get reimbursed is laughable.

The OP asked about Medicare Advantage. There should be less hassle about what is/is not covered - a friend who has it loves it. I avoided it for two reasons. First, it has a very narrow network. Second, if you decide to go back to regular Medicare they don't have to take you (they can "underwrite" you) so it may be a one-way street.

No need to feel bad the pendulum is swinging in the other direction, remember back in the day when Medicare would pay for everything without question? Like a pregnancy test for a 70 year old woman...they will eventually find the correct balance with stuff like this.

 

[Hermit]

OP here, Yes my husband has received a bill for the $800 lab work. He is trying to get the hospital lab company to send more information to Medicare to prove that the lab work was "medically necessary". Hospital keeps saying that Medicare should have paid this, it has never been denied by Medicare before, that they don't know what else to send Medicare, etc.

Regarding my physical that was incorrectly coded I have told my doctor I might have to leave his practice and go to another doctor over this (although I have not found another local doctor that I want to go to who is accepting new patients and who also accepts Medicare.). My doctor asked me not to leave and said he will get this billing matter straightened out. I hope that is the case since I don't really have another option for a GP.

Has anyone had any success getting reimbursed by Medicare for payments out of pocket that Medicare was suppose to pay? I have filed claims with Medicare for my out of pocket costs for when I was incorrectly charged a double deduction in 2017 and for my out of pocket costs when my Medicare was incorrectly terminated. I was told by Medicare to file these claims. But it has been 3 months for one claim and 6 weeks for the other and I have heard nothing. I have called Medicare and they say these claims are handled by an outside contractor and they cannot do anything.

I think I am doomed using Medicare. I though Medicare would be smooth sailing but it has turned out to be a big hassle and does not pay my medical bills. But I guess living in the U.S. and being over 65 I have no other option. I wonder if a Medicare Advantage plan would be better than traditional Medicare?

My Dad, who died many years ago, kept a very large pencil spread sheet of all his Medicare charges and when they were billed and when they were paid along with all the details. He spent quite a bit of time working issues through the system, but he was very patient and would just let Medicare work through its process. I don't know if the system has changed much in the last 25 or 30 years.

I have Medicare Advantage and have had one issue with billing for a procedure. It took about a year to get it straightened out, but it did get straightened out. The urgent care facility that did the procedure was very quick to bill me and note that I had signed a form that said I was "ultimately responsible for the charge." I spent some time on the phone with them explaining that they needed to correct their billing codes rather than harassing me. Trying to get them and the Advantage people who they had a contract with to talk to each other rather than funneling everything through me was a royal pain. All other charges have gone through without any issue.

It appears that the Advantage people follow the Medicare charging practices exactly with the only difference being the negotiated rates. The rates are ridiculously lower than what the providers charge as a standard fee. Something on the order of 10%.

 

[youbet]

First, it has a very narrow network.

This depends on the particular Medicare Advantage plan. For example, DW's plan is accepted anyplace that accepts Medicare assignment. Shop around.

Second, if you decide to go back to regular Medicare they don't have to take you (they can "underwrite" you) so it may be a one-way street.

Yes. DW was willing to take the risk and went Medicare Advantage and, with her broad network plan, she's pleased after 5 years. She's had significant health problems to deal with too........ I didn't want to take the risk so I'm on regular Medicare with a type F supplement.

In terms of problems dealing with Medicare:

1. Both Medicare and Social Security are OK if your issues are routine. Go outside of routine, and they become staggeringly incompetent. The bureaucracy renders even workers trying to help you helpless

2. DW has more success and less frustration dealing with her particular Medicare Advantage plan than I do with Medicare. Amazingly, when she calls and doesn't get an immediate answer, someone actually gets back to her.

3. The perfect storm occurs when you have an issue that involves both Medicare and Social Security. This usually involves premiums since SS collects premiums for Medicare. For example, DW's monthly SS is only a few dollars so instead of receiving a monthly SS benefit reduced by her Part B premium, she receives a bill which is supposed to be for the amount left to be paid after her entire SS is credited to the bill. For years, she's struggled to get them to bill her the appropriate amount or bill her at all.

 

[gayl]

I had a hard time but my local State Representative's office (thank you Desaulnier) fixed it in a day ). Not positive what the issue between SSA and Medicare was but I have suspicions & 1 call from them fixed it

 

[Katsmeow]

OP here, Yes my husband has received a bill for the $800 lab work. He is trying to get the hospital lab company to send more information to Medicare to prove that the lab work was "medically necessary". Hospital keeps saying that Medicare should have paid this, it has never been denied by Medicare before, that they don't know what else to send Medicare, etc.

There is an appeal process. I am not sure what the process is or the time limits but Medicare should I think give you that information.

I wonder if a Medicare Advantage plan would be better than traditional Medicare?

All I can say that a relative that I have who is on Medicare Advantage has had many, many fewer options for providers than my mother and husband on traditional Medicare have had. For example, the relative in going to skilled nursing had to go to one that would take her plan. My mom can go to any that take Medicare (and so far they all take it from the ones I've dealt with). Providers have generally said "good" when I tell them my mom is on traditional Medicare. Rightly or wrongly they seem to feel that it provides broader coverage with less hassle.

I can understand some of the appeal for Medicare Advantage but I will never do it because there is no guarantee you can go back to traditional Medicare and get a supplement. I just will not take that risk.

 

[Bamaman]

Many Medicare issues are being discussed here. I am on Medicare with a good supplement and Part D for medicine. I am also a type II diabetic that is very stable on an insulin pump.

First time CVS filled my insulin prescription, I like to have had a heart attack. At $255 a vial for insulin, my copayments were staggering. I went back to my endocrinologist and had them change some code numbers on the prescription where it would go to Medicare Part B. Now I pay a fair copay for insulin and pump supplies.

I have found my Part B coverage to be exceptionally well managed. I have to see the doctor every 90 days and his prescriptions are for 90 days. Medicare requires CVS to document my doctor visits and that I am being carefully managed.

Let me just warn about Medicare Advantage. Not all doctors or hospitals accept Advantage although most accept traditional Medicare. There is a large hospital to the north of me that has purchased physicians practices in 6 states and is managing hospitals across the region. They have made the business decision to not take Medicare Advantage in any of their hospitals or clinics. Their network includes 1700 doctors, PAs and Nurse Practitioners. Thousands of patients on Advantage had to switch doctors and hospitals--often in different cities. Just be careful and verify your sitiuation prior to going with Advantage.

 

[John Galt III]

I
The OP asked about Medicare Advantage. There should be less hassle about what is/is not covered - a friend who has it loves it. I avoided it for two reasons. First, it has a very narrow network. Second, if you decide to go back to regular Medicare they don't have to take you (they can "underwrite" you) so it may be a one-way street.

I was all set to get on Medicare with a supplement since I have been hearing from hospital staff how traditional Medicare and a supplement is so much better than a Medicare advantage plan. Now this ! My mom decided to go with a Medicare Advantage plan since her premiums would be about $200 lower per month than with traditional Medicare and a supplement. Luckily the hospital she goes to is in network. But some rehab and skilled nursing places are not. I've been watching her claims history online and she has some copays, like $40 for an office visit, $15 for lab work. The worst part of her coverage is that she has a $300 copay for each ambulance ride. She has a daily copay for hospital stay of $230 ? per day until a max if $1,650 . Rehab is free for the first 20 days, then costs $190 per day until some max is reached. Traditional Medicare has copays also, right? The insurance company is doing its job right, as far as I can remember, but her providers are billing her for things that she does not owe, and I am often on the phone correcting them, and convincing my mom she does not owe it.

 

[athena53]

Let me just warn about Medicare Advantage. Not all doctors or hospitals accept Advantage although most accept traditional Medicare. <snip>Just be careful and verify your situation prior to going with Advantage.

I've read- maybe here on another discussion- that M.D. Anderson in Houston doesn't take Medicare Advantage. I sincerely hope I'll never need them (don't even live in the area) but that's a pretty big player opting out.

 

[Hermit]

I went with Medicare Advantage because when I get too old to live in the mountains, I will move to the Denver area and I have every intention of enrolling in the Kaiser Permanente system in Denver. They have their own facilities and doctors and are always rated at the top in the area. They have recently started providing Medicare Advantage in my local area using the same doctors I currently use. I may switch to them, but they are more expensive the Humana and don't offer negotiated rates for dental as part of their package.

 

[Mark24609]

I am 66, DH is 67. When we each turned 65 we signed up for traditional Medicare, a Medicare supplement "G" and a part D policy. We thought that when we made it to 65 and got on Medicare (and ditched our high deductible health insurance policies) we would be in much better shape regarding health insurance. Not so. We have had constant problems with Medicare, doctor screw ups, many calls to Medicare, having to pay for things that should have been paid by Medicare, etc. We have no problem with our Medicare supplement, but the supplement only pays if Medicare pays. Some examples of problems we have had in the past year:



1. I had Medicare under my own SS number initially and then when I started receiving spousal SS in 2017 I got a new Medicare number based on DH's SS number. When I got the new Medicare # I had already paid my $183 Medicare part B deductible for 2017. Medicare made me pay a second $183 deductible for 2017 after I got the new Medicare number. Everyone I have talked to at Medicare says this should not have happened but it did. After numerous calls to Medicare and appeals i just gave up and paid the second $183 deductible to preserve my credit rating.



2. I got a physical in 2017. I told my doctor I wanted the Medicare Annual Wellness visit which Medicare would pay for. Instead I was billed $400 for a regular annual physical for which Medicare will not pay. I have worked diligently with my doctor's office to get the coding on this physical changed so that Medicare will pay but so far no luck. So I guess I am stuck paying $400.



3. I was the victim of Social Security identity theft in early 2018. Someone fraudulently claimed my Social Security and received around $5000. I finally got that stopped and got my spousal social security restarted. When the fraudulent SS claim was stopped my Medicare was also terminated. It took a couple of months to get Medicare reinstated. During that time I got sick and had to pay out of pocket to go to the doctor. So far Medicare has refused to reimburse me.



4. DH has developed a fairly serious medical problem and his doctor order laboratory tests in order to diagnose what the problem is. Medicare has denied the lab bill of $800 and have said the lab test are not "medically necessary." He has been on the phone all day today with Medicare, his doctor and the lab that did the test. His doctor says he has never heard of Medicare denying these particular tests.



I wonder if anyone else is having all these problems with Medicare. I guess I just wanted to rant. Thanks for listening.

I am sure glad I have Kaiser Senior Advantage. Never have to worry

 

[harllee]

OP here, to my knowledge we don't have Kaiser here in North Carolina where I live, at least I have never heard of it.