Where Does Medicare Fall Short?

[MRG]

DW & I were discussing and realized we don't know the steps/process of medicare.

I'm on medicare A&B plus a plan G.
If I go to a doctor (first time this year) that takes medicare: Do I pay anything at the doctor office ?
Or do I wait a few months for some letters from medicare or my plan G to say what I owe?

Do you have plan D coverage too? That's what pays for meds.

 

[CRLLS]

^ +1

I never pay a service provider until both Medicare and the supplement both agree on the same amount. It is not uncommon for some give and take in amounts between the Dr's office and Medicare before the numbers are finalized.

A couple weeks ago I had some pre-op tests done for a 2nd time. The front office said I had an outstanding balance. How would I like to pay? Their policy was to have balances paid in full before more services were provided. I replied with "It is my policy to not pay a bill until all 3 involved (Medicare, supplement and Dr's billing) all agreed on the same amount. I then immediately pay the bill. I haven't received a bill yet from your office or Medicare EOB. How are we going to resolve this?" They let me get the tests done without paying on the spot as they should.

 

[Sunset]

Do you have plan D coverage too? That's what pays for meds.

Yes I do, and I know to check each year to see which plan D is best for me.

 

[bmcgonig]

DW & I were discussing and realized we don't know the steps/process of medicare.

I'm on medicare A&B plus a plan G.
If I go to a doctor (first time this year) that takes medicare: Do I pay anything at the doctor office ?
Or do I wait a few months for some letters from medicare or my plan G to say what I owe?

No. You’ll get a bill later for your deductible from the first provider(s) of the year . That’s the first $2xx . After that nothing until the next year.

 

[Scuba]

^ +1

I never pay a service provider until both Medicare and the supplement both agree on the same amount. It is not uncommon for some give and take in amounts between the Dr's office and Medicare before the numbers are finalized.

A couple weeks ago I had some pre-op tests done for a 2nd time. The front office said I had an outstanding balance. How would I like to pay? Their policy was to have balances paid in full before more services were provided. I replied with "It is my policy to not pay a bill until all 3 involved (Medicare, supplement and Dr's billing) all agreed on the same amount. I then immediately pay the bill. I haven't received a bill yet from your office or Medicare EOB. How are we going to resolve this?" They let me get the tests done without paying on the spot as they should.

Have you ever run into a provider that won’t provide the service without up front payment? I’m not on Medicare yet but had to pay my portion for my recent shoulder surgery before the facility or the surgeon would perform the surgery.

 

[harllee]

Have you ever run into a provider that won’t provide the service without up front payment? I’m not on Medicare yet but had to pay my portion for my recent shoulder surgery before the facility or the surgeon would perform the surgery.

I don't think this happens if the provider takes Medicare and you are on traditional Medicare and a supplement. Might apply is you are on Medicare Advantage or if you have no Medicare Supplement.

 

[bmcgonig]

Have you ever run into a provider that won’t provide the service without up front payment? I’m not on Medicare yet but had to pay my portion for my recent shoulder surgery before the facility or the surgeon would perform the surgery.

Yes. Had mohs surgery a few years back and they did that.

 

[harllee]

Yes. Had mohs surgery a few years back and they did that.

Were you on Medicare and they wanted payment upfront?

 

[athena53]

I replied with "It is my policy to not pay a bill until all 3 involved (Medicare, supplement and Dr's billing) all agreed on the same amount. I then immediately pay the bill. I haven't received a bill yet from your office or Medicare EOB. How are we going to resolve this?" They let me get the tests done without paying on the spot as they should.

I can't believe all places would agree with this but I'm glad yours did. Here's a good reason to do it this way, which I learned from the friend who answers questions from Medicare beneficiaries:

It's January 2. You visit Provider A. They check your coverage, there's a deductible and they ask you to pay the deductible.

On January 15 you visit Provider B. They also check, see that the deductible hasn't been satisfied yet and ask you to pay the deductible.

Whichever provider bills Medicare first will get paid the approved amount minus the deductible, which is correct. The second provider to bill will get paid the full approved amount because the deductible has been satisfied, They owe you money. It may take them awhile to figure it out and reimburse you.

I also had a bewildering cluster of bills from the facility when DH had recurring treatments for a small leg ulcer- different dates, different procedures coded together on each statement. They had the standard boilerplate that all insurance coverages had been applied. They hadn't- it took some fancy Excel footwork to realize the Medicare supplement hadn't been billed even though the facility had the information. The supplement carrier confirmed this. I copied 30 pages of EOBs and sent them to the supplement carrier and they promptly processed the claims.

DH at that point was 77, in failing heath and never was very good with Excel. I wonder how many beneficiaries miss errors such as this.

 

[bmcgonig]

Were you on Medicare and they wanted payment upfront?

No. Before Medicare

 

[Scuba]

I don't think this happens if the provider takes Medicare and you are on traditional Medicare and a supplement. Might apply is you are on Medicare Advantage or if you have no Medicare Supplement.

Good to hear, thanks!

 

[Koolau]

Have you ever run into a provider that won’t provide the service without up front payment? I’m not on Medicare yet but had to pay my portion for my recent shoulder surgery before the facility or the surgeon would perform the surgery.

Both at home and on the mainland, my various clinics/docs post signs saying (words to the effect) co-pays are due at time of service. But I've never been asked for money up front. In fact, I've had a couple of bills that finally caught up with me 6 months post service. Apparently, not a problem. Both organizations I use are HUGE and apparently "trust" me (as in - they have apparently run credit checks on me!) YMMV

 

[CRLLS]

Have you ever run into a provider that won’t provide the service without up front payment? I’m not on Medicare yet but had to pay my portion for my recent shoulder surgery before the facility or the surgeon would perform the surgery.

I have not. I have been on Medicare with Plan FHD then Plan G supplements for 5 years now. I have had a few surgeries over those years too. I have not run into this. I do sign a paper that I am responsible for paying above and beyond what the insurance doesn't pay. Of course, I do pay the annual deductible, but only after the bills are submitted and reconciled with the insurance. Maybe I've just got lucky with our service providers. Or maybe they check my credit rating.

 

[Morgan22]

Both at home and on the mainland, my various clinics/docs post signs saying (words to the effect) co-pays are due at time of service. But I've never been asked for money up front. In fact, I've had a couple of bills that finally caught up with me 6 months post service. Apparently, not a problem. Both organizations I use are HUGE and apparently "trust" me (as in - they have apparently run credit checks on me!) YMMV

I'm not sure if you are saying this as a joke, but it is not possible for a hospital system to run a credit check on you. You would need to give them permission. And hospital systems normally just don't have the time of resources to do that for its patients. Now I agree, billing can take 6 months or longer to catch up to the patient. It depends on staffing and the time it takes for insurance companies to settle with the hospital system.

 

[athena53]

I'm not sure if you are saying this as a joke, but it is not possible for a hospital system to run a credit check on you. You would need to give them permission.

I'd wondered about that- they have your SSN and I have to admit I don't give a thorough reading to all the paperwork they put in front of me (it's mostly an agreement that I'm responsible for whatever Medicare and the supplement don't pay). I had a colonoscopy a year ago and they didn't ask for anything up front and it was 100% covered. I realized, though that I froze my credit years ago. If they'd tried to run a credit check on me I'm sure I would have gotten a call.

 

[Scuba]

My recent experience is that there is a huge variation depending on the specific provider. DH’s heart surgery was done at a Level 4 trauma hospital. They didn’t ask for any up front payment and once they did bill us, they offered payment plans up to 36 months at zero interest.

My shoulder surgery was done at an outpatient surgery center in Newport Beach. They required payment up front and when I asked about options, the only one they had was 3 months with zero interest. My surgeon also required his fee up front.

Maybe the difference is size of provider? One was a larger hospital system that accepts Medicaid patients. The other was a relatively small independent ortho practice and surgery center. We have Anthem PPO insurance and neither of us is on Medicare yet.

 

[RS53576GG]

My experiences with Medicare and my supplemental insurance policy have been very good. Here's an example. Last year I had 3 stents put in 3 heart arteries. Two separate operating room procedures and 10 days in the hospital. The first day was in Intensive Care. On the last day I was discharged at 6 PM so I only spent 9 nights in the hospital. With cardio rehab and numerous doctor's visits for various things the entire financial trail took 8 months to run its course. Just for fun I tabulated all the expenses and what was paid.


Total List Price For Everything - $364,581.93


Total Amount Paid by Medicare A & B - $27,589.59


Total Amount Paid by BC-BS Plan F - $3,553.84


Total Amount Paid by Me - Zero


Of course I've been paying for Medicare B and Blue Cross - Blue Shield of Arizona Plan F and BC-BS AZ Value PDP drug plan so it wasn't really zero cost, but it didn't cost me anything more than what I've been paying for my healthcare insurance. This year (2022) I've been paying $170.10 for Medicare B, $197.07 for BS-BS AZ Plan F and $36.20 for BC-BS AZ Value PDP drug plan each month. So $400 a month for all my health insurance needs. The drug plan has a deductible and copay but they aren't enough to justify the added expense of the next level drug plan.


I don't have dental insurance or any kind of optical insurance. My teeth are in good shape so that's not a big expense. I've had one crown replacement in the last 10 years. Other than that it's been the usual biannual dentist visits for cleaning, x-rays, etc.


Medicare covers eye doctor exams and probably most procedures, but I haven't needed to have anything done so I can't say this for certain. If I want the eye exam prescription it's an extra $45 payment to my eye doctor. I don't get it unless I'm planning to buy some glasses in the near future. I only use glasses for reading, working on PC, etc. In the last 22 years since having LASIK done I've probably saved enough on glasses to pay for a good percentage of the LASIK procedure. ($4,400 in 2000)


The only thing I've had done in the last four years that Medicare wouldn't pay for was a Cardiac Calcium Test that measures the calcium buildup in your heart arteries. It was $104 which I was happy to pay since my cardiac doctor thought it was a good idea. My score came back as nearly zero. Turns out the CCT test doesn't detect plaque and plaque is usually what causes heart artery obstructions. Seven months after having the CCT I needed 3 stents, which gives you an idea of what the CCT was worth. Now I understand why Medicare won't pay for it.


It's pretty clear that Medicare beats down the list prices on everything they pay for. Here's a somewhat humorous case I experienced. For a while after having the stents put in I needed to have my blood clotting ability checked each week so the anticoagulant dosage I was taking could be adjusted. I'd stop by my cardiac doctor's office and they'd check it and we'd decide how much we'd change the dosage for the following week. This usually took 15 minutes or so. I noticed on my Medicare statement that the cardiac doc's office was billing them $10 for each weekly test and accompanying chit-chat about dosage adjustment. Seemed like a bargain to me. Medicare was paying them $4.29.


Overall I'm very satisfied with Medicare and the healthcare infrastructure they've created for us. Your mileage may vary.

 

[Rianne]

My experiences with Medicare and my supplemental insurance policy have been very good. Here's an example. Last year I had 3 stents put in 3 heart arteries. Two separate operating room procedures and 10 days in the hospital. The first day was in Intensive Care. On the last day I was discharged at 6 PM so I only spent 9 nights in the hospital. With cardio rehab and numerous doctor's visits for various things the entire financial trail took 8 months to run its course. Just for fun I tabulated all the expenses and what was paid.


Total List Price For Everything - $364,581.93


Total Amount Paid by Medicare A & B - $27,589.59


Total Amount Paid by BC-BS Plan F - $3,553.84


Total Amount Paid by Me - Zero


Of course I've been paying for Medicare B and Blue Cross - Blue Shield of Arizona Plan F and BC-BS AZ Value PDP drug plan so it wasn't really zero cost, but it didn't cost me anything more than what I've been paying for my healthcare insurance. This year (2022) I've been paying $170.10 for Medicare B, $197.07 for BS-BS AZ Plan F and $36.20 for BC-BS AZ Value PDP drug plan each month. So $400 a month for all my health insurance needs. The drug plan has a deductible and copay but they aren't enough to justify the added expense of the next level drug plan.


I don't have dental insurance or any kind of optical insurance. My teeth are in good shape so that's not a big expense. I've had one crown replacement in the last 10 years. Other than that it's been the usual biannual dentist visits for cleaning, x-rays, etc.


Medicare covers eye doctor exams and probably most procedures, but I haven't needed to have anything done so I can't say this for certain. If I want the eye exam prescription it's an extra $45 payment to my eye doctor. I don't get it unless I'm planning to buy some glasses in the near future. I only use glasses for reading, working on PC, etc. In the last 22 years since having LASIK done I've probably saved enough on glasses to pay for a good percentage of the LASIK procedure. ($4,400 in 2000)


The only thing I've had done in the last four years that Medicare wouldn't pay for was a Cardiac Calcium Test that measures the calcium buildup in your heart arteries. It was $104 which I was happy to pay since my cardiac doctor thought it was a good idea. My score came back as nearly zero. Turns out the CCT test doesn't detect plaque and plaque is usually what causes heart artery obstructions. Seven months after having the CCT I needed 3 stents, which gives you an idea of what the CCT was worth. Now I understand why Medicare won't pay for it.


It's pretty clear that Medicare beats down the list prices on everything they pay for. Here's a somewhat humorous case I experienced. For a while after having the stents put in I needed to have my blood clotting ability checked each week so the anticoagulant dosage I was taking could be adjusted. I'd stop by my cardiac doctor's office and they'd check it and we'd decide how much we'd change the dosage for the following week. This usually took 15 minutes or so. I noticed on my Medicare statement that the cardiac doc's office was billing them $10 for each weekly test and accompanying chit-chat about dosage adjustment. Seemed like a bargain to me. Medicare was paying them $4.29.


Overall I'm very satisfied with Medicare and the healthcare infrastructure they've created for us. Your mileage may vary.

Thank you for that and so interesting. Now, why can't healthcare before Medicare come close to that? I get we're a capitalist society and something to do with lobbyists, and I think as of July 1 hospitals are required to post the cost of procedures and services so we're moving in the right direction. You can at least compare costs from hospital to hospital and see the huge difference in cost that we did not have access before.

 

[RS53576GG]

My guess is that every health insurance company makes a deal with all the healthcare and pharmaceutical companies for what they're willing to pay for each procedure, each drug, etc. You always read about the exorbitant list prices in the news but the actual price your health insurance is paying is something else. One of the benefits of getting health insurance is that the bill is lowered to what your health insurance provider is paying. After that you pay a deductible, co-payment and whatever else the health insurance company can squeeze out of you. So even if you have a high deductible you could end up paying less than if you didn't have insurance at all.


I think this why healthcare prices are so difficult to nail down. Depending on your insurance company the price could vary quite a bit. I looked up the list price for a stent operation at the hospital where mine were done and it was something ridiculous. I don't remember the exact price but I think it was over $100,000. If you don't have insurance they'll send you a bill with the list prices on it. After that it's up to you to negotiate a better price. I had no idea that Medicare is pushing prices down so low but this appears to be the case.


I told a friend what the list prices were and the amount Medicare and BC-BS AZ paid and he didn't believe me. He's sure there are some kind of under the table payments that aren't made public. Maybe he's right. Or maybe he has an irrational fondness for conspiracy theories. All I know is that the paperwork I got from Medicare and BC-BS AZ says how much the billed price was and how much they paid. Maybe Medicare pays little green men from Mars to make secret payments to the doctors so they can buy fancy cars and big speed boats and have a mistress or gigolo (depending on preference) in an apartment in Monte Carlo. All I know for sure is that I paid nothing more than my regular monthly insurance payments.


If they are really paying more for a mistress in Monte Carlo I'd appreciate it if they'd send me a picture of her so I can see what my health insurance payments are paying for. Just an academic interest, nothing more.

 

[Rianne]

My guess is that every health insurance company makes a deal with all the healthcare and pharmaceutical companies for what they're willing to pay for each procedure, each drug, etc. You always read about the exorbitant list prices in the news but the actual price your health insurance is paying is something else. One of the benefits of getting health insurance is that the bill is lowered to what your health insurance provider is paying. After that you pay a deductible, co-payment and whatever else the health insurance company can squeeze out of you. So even if you have a high deductible you could end up paying less than if you didn't have insurance at all.


I think this why healthcare prices are so difficult to nail down. Depending on your insurance company the price could vary quite a bit. I looked up the list price for a stent operation at the hospital where mine were done and it was something ridiculous. I don't remember the exact price but I think it was over $100,000. If you don't have insurance they'll send you a bill with the list prices on it. After that it's up to you to negotiate a better price. I had no idea that Medicare is pushing prices down so low but this appears to be the case.


I told a friend what the list prices were and the amount Medicare and BC-BS AZ paid and he didn't believe me. He's sure there are some kind of under the table payments that aren't made public. Maybe he's right. Or maybe he has an irrational fondness for conspiracy theories. All I know is that the paperwork I got from Medicare and BC-BS AZ says how much the list price was and how much they paid. Maybe Medicare pays little green men from Mars to make secret payments to the doctors so they can buy fancy cars and big speed boats and have a mistress or gigolo (depending on preference) in an apartment in Monte Carlo. All I know for sure is that I paid nothing more than my regular monthly insurance payments.


If they are really paying more for a mistress in Monte Carlo I'd appreciate it if they'd send me a picture of her so I can see what my health insurance payments are paying for. Just an academic interest, nothing more.

Very awesome summary. My bold for your first paragraph. That is exactly what we've done since 2014. A very efficient way to handle healthcare and saved us boatloads of $$. Our deductible apiece is $6000 so $13,000 as a family. HC costs on average for the last 8 years, $3000 for both of us, meaning $1500/each. Now, we will be paying $7000/year for both of us ($3500/each), Medicare premiums and G plan. Not complaining!!

 

[Morgan22]

My guess is that every health insurance company makes a deal with all the healthcare and pharmaceutical companies for what they're willing to pay for each procedure, each drug, etc.

<snip>

I think this why healthcare prices are so difficult to nail down. Depending on your insurance company the price could vary quite a bit.

<snip>

I can confirm that you are correct in your thoughts on the healthcare side. I cannot confirm the pharmaceutical side.

 

[pirsquared]

^ +1

I never pay a service provider until both Medicare and the supplement both agree on the same amount. It is not uncommon for some give and take in amounts between the Dr's office and Medicare before the numbers are finalized.

A couple weeks ago I had some pre-op tests done for a 2nd time. The front office said I had an outstanding balance. How would I like to pay? Their policy was to have balances paid in full before more services were provided. I replied with "It is my policy to not pay a bill until all 3 involved (Medicare, supplement and Dr's billing) all agreed on the same amount. I then immediately pay the bill. I haven't received a bill yet from your office or Medicare EOB. How are we going to resolve this?" They let me get the tests done without paying on the spot as they should.

I have a question about the bolded. My DH started Medicare recently and we are trying to make sure we understand the Medicare/supplement interaction. DH had an appointment and it was billed to Medicare. It was approved and the amount, which is less than our $233 Plan G deductible, has been applied towards his deductible and we know we will need to pay that amount. This claim, however, has not yet showed up in any way on his online account for the supplement policy. Does Medicare not send the claim on to the supplement if it is below the deductible (and thus would not be paid by the supplement) or does the supplement need to apply the amount to the deductible also in some way?

Thanks!

 

[Koolau]

I'm not sure if you are saying this as a joke, but it is not possible for a hospital system to run a credit check on you. You would need to give them permission. And hospital systems normally just don't have the time of resources to do that for its patients. Now I agree, billing can take 6 months or longer to catch up to the patient. It depends on staffing and the time it takes for insurance companies to settle with the hospital system.

No joke, though it's "funny" that it takes 6 months sometimes to figure out which entity is owed money (doc, ER, hosp., etc.) and who is responsible for paying it (MC, Supplement, me.)

IIRC I did give them permission to run a credit check though it's been quite a while now. I think I asked "Why do you need my SSN?" Then, IIRC, they indicated they would be running a credit check. Credit checks are very quick. Companies that routinely need such info have arrangements with the major credit rating companies. Quick as a phone call IIRC. You go to buy a car and they will gladly run a check on you if you want to use "their" credit to buy. YMMV

 

[Telly]

........DH had an appointment and it was billed to Medicare. It was approved and the amount, which is less than our $233 Plan G deductible, has been applied towards his deductible and we know we will need to pay that amount. This claim, however, has not yet showed up in any way on his online account for the supplement policy. Does Medicare not send the claim on to the supplement if it is below the deductible (and thus would not be paid by the supplement) or does the supplement need to apply the amount to the deductible also in some way?

Thanks!

Medicare sends the claim on to the Medigap insurer.

Here is an example of what you are asking, a $147 charge, first bill of the calendar year, so had all of the $233 deductible to go:
My Plan N EOB has columns for:
Amount Charged ($185); Medicare Approved Amount ($147.28); Applied to Medicare Deductible ($147.28); Medicare Paid ($0); Plan Cost Share [this is unique to Plan N]; Your Plan Paid ($0); and then an Item & Notes column.
So since the $233 deductible was not met yet, neither Medicare or the Medigap paid out anything, it's all mine to pay.
I see around a 2-3 week delay after Medicare makes a determination/pays, to the Medigap Plan taking action and showing up online. Sometimes it's faster than that.

 

[Sunset]

Medicare sends the claim on to the Medigap insurer.

Here is an example of what you are asking, a $147 charge, first bill of the calendar year, so had all of the $233 deductible to go:
My Plan N EOB has columns for:
Amount Charged ($185); Medicare Approved Amount ($147.28); Applied to Medicare Deductible ($147.28); Medicare Paid ($0); Plan Cost Share [this is unique to Plan N]; Your Plan Paid ($0); and then an Item & Notes column.
So since the $233 deductible was not met yet, neither Medicare or the Medigap paid out anything, it's all mine to pay.
I see around a 2-3 week delay after Medicare makes a determination/pays, to the Medigap Plan taking action and showing up online. Sometimes it's faster than that.

We just got our first one, and while our supplemental plan is different (G), it's very similar.
Doc office charged a bunch, medicare allowed less for each one, Plan G paid zero , and the allowed medicare amounts totaled $202 , so it's all our bill as it's less than the deductible of $233.

Our supplemental plan had the EOB, which we looked at online, after seeing the doctor office bill (which nicely listed the medicare and supplemental numbers).
Both agreed with each other, which was nice to see it work smoothly.