Do I need to pre approve with Medicare a dermatology visit and Basal cell cancer removal?

[Time2]

I just received a Medicare statement. It says service approved, NO. Provider charged $378, Medicare Approved amount $0.00, Medicare Paid $0.00.
You may be billed $0.00, and then the note is "the cost of care before and after the surgery or procedure is included in the approved amount of that service."
I don't see where my doc is getting paid! Also, they didn't get it all the first time, so I had to go back for a more extensive procedure. I was about to file an appeal, but saw the Maximum you (I) may be billed is $0.00, but, I want my doc to get paid.
Any thought about this.

 

[sengsational]

If you are not on the hook for payment, I would not appeal.

That's from someone who has been on tMedicare for a grand total of 9 months, so take that advice with a grain of salt.

What can happen is the provider realizes they didn't get paid and they re-file with a different jumble of codes, then they do get paid. Or not. But unless you signed the "Medicare probably won't pay" form, you probably won't be billed.

 

[MBSC]

It's called Global Billing. The surgery payment included payment for follow-up visits for a specified number of days. IOW, the provider was paid in advance.

https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

 

[Healthy Lifestyle]

Is that a Medicare advantage plan?

 

[Time2]

Is that a Medicare advantage plan?

No.

 

[Car-Guy]

I had a ~1" Basal SC removed from my leg earlier this year under a MC advantage plan. FWIW, here's the cost breakdown.

Amount billed$658.00
Total cost approved$160.04
Plan's share$137.24
Your share$20.00

By the way, the in office procedure only took 15 mins (or less) totally painless during and after and no re-occurrence.

 

[Time2]

My first bill is $378, they didn't get it all so I expect the second to be an additional charge. The second was more extensive with cauterization. There will be a tissue inspection charge coming from someone. Normal procedure, but I'm glad they inspected, the found one edge where the missed some on the first cut.

 

[Koolau]

My first bill is $378, they didn't get it all so I expect the second to be an additional charge. The second was more extensive with cauterization. There will be a tissue inspection charge coming from someone. Normal procedure, but I'm glad they inspected, the found one edge where the missed some on the first cut.

I thought most surgeons now used the MOHS method where they do pathology with each removal in one visit (IOW they remove some, check it and then take some more until they find no more cancer cells.) DW had this done and it took 3 passes and about 3 hours.

I don't recall what she had to pay but it was very little as I recall. YMMV

 

[Time2]

Ya, the doc said, one edge still was cancerous. I said, but I wish you knew what edge. Her response was something about we don't do MOHS. I'm not sure if she overcompensated because of my comment (I hope so), but it went from a 7/16" across to 3/4". It's been 5 weeks now and still a big red mark, but I no longer notice that I have it. I stung for about 10 days, then started itching.

 

[Graybeard]

I thought most surgeons now used the MOHS method where they do pathology with each removal in one visit (IOW they remove some, check it and then take some more until they find no more cancer cells.) DW had this done and it took 3 passes and about 3 hours.

I don't recall what she had to pay but it was very little as I recall. YMMV

I have had lots of skin cancers removed. Mohs is up to the discretion of the doctor, I assume based upon the biopsy. I have had just 1 several years ago with a 2nd scheduled in January.

 

[Time2]

I have had lots of skin cancers removed. Mohs is up to the discretion of the doctor, I assume based upon the biopsy. I have had just 1 several years ago with a 2nd scheduled in January.

It could very well be the first cut was a biopsy and the biopsy showed all the edges were clear except one. i.e. she got most of it with the biopsy. Just speculation.

 

[5Miler]

I thought most surgeons now used the MOHS method where they do pathology with each removal in one visit (IOW they remove some, check it and then take some more until they find no more cancer cells.) DW had this done and it took 3 passes and about 3 hours.

I don't recall what she had to pay but it was very little as I recall. YMMV

I had two MOHS procedures 3 years ago but this August I had a procedure on my shoulder for Basal Cell and was not given an option for MOHS. All this done by the VA. I was given a choice of normal surgery for removal or "freeze and scrape" procedure. The former would give me 95% efficacy rate and the latter an 80% so I opted for the normal surgery. Since it wasn't MOHS, it took a week to find out that they got it all the first try. It was a 4 or 5 inch incision across the top of my shoulder, very different from a MOHS. Total time in the chair for the procedure was about 1.5 hrs.

 

[gcgang]

Yesterday, two hours before my craniotomy, I get notice UHC insurance is still”pending”, I’m now self pay, and the estimated cost is $157k. I guess they figure it will help reduce the stress from having your skull cracked open. lol.

Surgery went well but won’t know results/treatment plan for a week or so, and I still don’t have an answer on the coverage.

This isn’t the first surgery here and the other was covered so I have faith it will be taken care of and my patent advocate here at MDA assured me it was top of her list.

Still, it just reinforces the scepticism towards our grossly inefficient health care system.

 

[grasshopper]

My dermatologist pretty much only does MOHS on your face, so that as little tissue as possible is removed.

 

[Koolau]

My dermatologist pretty much only does MOHS on your face, so that as little tissue as possible is removed.

Yeah, I hadn't thought of that. I guess in places that don't typically show, they can just "dive in" and take extra - and then go back in the rare instance where they don't get it all. For the face, it probably makes more sense to be as conservative as possible with MOHS. Thanks for answering my question.

 

[RetMD21]

Yesterday, two hours before my craniotomy, I get notice UHC insurance is still”pending”, I’m now self pay, and the estimated cost is $157k. I guess they figure it will help reduce the stress from having your skull cracked open. lol.

...

That's awful is this Medicare advantage or commercial insurance?

 

[gcgang]

Medicare Advantage. PPO. I had been raving about how great their coverage had been. I’d racked up $120k billing by the providers. I had been able to go where I wanted (MDAnderson). They had accepted $40k from UHC as payment in full with my share being only $600. My doc assures me this is necessary surgery and will be covered and not to worry. Still, I really didn’t need the additional stress, nor do I now. But, I guess I’ve always performed better under stress. lol.

 

[RetMD21]

It just seems cruel. I am not sure you are really "self pay" since the MA plan is legally obligated to cover medically necessary services. Best wishes for a speedy recovery

 

[oldtimer]

I just received a Medicare statement. It says service approved, NO. Provider charged $378, Medicare Approved amount $0.00, Medicare Paid $0.00.
You may be billed $0.00, and then the note is "the cost of care before and after the surgery or procedure is included in the approved amount of that service."
I don't see where my doc is getting paid! Also, they didn't get it all the first time, so I had to go back for a more extensive procedure. I was about to file an appeal, but saw the Maximum you (I) may be billed is $0.00, but, I want my doc to get paid.
Any thought about this.

A Medicare statement is not a bill. You may or may not get a actual bill from the service provider. Wait & be patient, don't rush to pay a bill that does not yet exist.

 

[isisdave]

Mohs (it's the name of the inventor, Frederic Mohs, not an acronym) is most usually done for face and scalp, where there isn't a lot of extra skin to sacrifice for wide margins, and the result is very visible. I've had eight, and another dozen regular excisions of BCCs. I think my doctor named his boat after me.

Medicare notices like the one you got (where the provider hasn't been paid but your "may be billed" amount is zero) usually mean the biller has done something wrong and needs to resubmit. To me, it's odd for a dermatology practice that does a bunch of these every day, but they'll figure it out. Don't rattle the cage.

 

[2retireearly]

I had a large squamous removed from shin area, the dermatologist sent me to a plastic surgeon.Plastic surgeon became almost hostile when I asked about mohs. he said Dermatologists use mohs, but plastic surgeons don't. He was kind of a jerk. he did something called Frozen Section. he had the pathologist in the surgery with him. so the end result was about the same. He would remove sections and the pathologist would examine them right there. He said mohs would have taken hours and hours. I didn't like the look of the surgery. looked like a big shark bite..huge shark bite . but after 2 years it definitely looks much better, though there is still an indentation. but apparently plastic surgeons can get pissy about demonologists doing mohs.

 

[jrendt]

I had a ~1" Basal SC removed from my leg earlier this year under a MC advantage plan. FWIW, here's the cost breakdown.

Amount billed$658.00
Total cost approved$160.04
Plan's share$137.24
Your share$20.00

By the way, the in office procedure only took 15 mins (or less) totally painless during and after and no re-occurrence.

Isn't it interesting that the provider was OK accepting $160. So if you didn't have insurance you would be screwed twice: once because you had no insurance and second because you have to pay retail.

 

[shafer9]

I have had lots of skin cancers removed. Mohs is up to the discretion of the doctor, I assume based upon the biopsy. I have had just 1 several years ago with a 2nd scheduled in January.

After spending 35 years in the sun, I am a cancer factory. I go to the dermatologist approximately every two months, I can see these things coming a mile away. I find them and call up and make an appointment and go in and they remove them. Most of them are freeze and burn. But I’ve had lack of squamous cells That had to be removed in various forms, including Mohs surgery. At my age, I don’t worry about the cosmetics of this, I just want everything removed, so I don’t have to worry about it. I’ve also had some other cancers in the past that I should not have survived and I did, so Living big time in the bonus around and happy about it.

 

[Happily Retired 2019]

Medicare processes payment according to two codes-one is the CPT code which tells Medicare what procedure was performed, and the other code is the ICD code which tells Medicare what the diagnosis (or the reason) why the procedure (CPT code) was done. If the ICD is not listed as "medically necessary" under the CPT codes then a bill is denied. The Doctors office needs to investigate and file and appeal. Many do not and just bill a patient. Also, even if you sign that you will be responsible for payment, if Medicare does not pay, as long as the Doctor participates with Medicare, you cannot be billed. You can only be billed if that procedure is listed as never being payable by Medicare-I hope this helps. I worked 35 years in medical billing so I have seen so many patients pay a bill just because they got a bill. There are so many mistakes in the medical billing world and the shame of it is is that most people in the insurance industry as well that work in Providers offices just don't care.

 

[hopeisconstant]

I just received a Medicare statement. It says service approved, NO. Provider charged $378, Medicare Approved amount $0.00, Medicare Paid $0.00.
You may be billed $0.00, and then the note is "the cost of care before and after the surgery or procedure is included in the approved amount of that service."
I don't see where my doc is getting paid! Also, they didn't get it all the first time, so I had to go back for a more extensive procedure. I was about to file an appeal, but saw the Maximum you (I) may be billed is $0.00, but, I want my doc to get paid.
Any thought about this.

In almost all situations your Doctor will tell you, in advance of the procedure, if you are not covered.