Medicare Newbie Seeks Tips on Medical Billing Coding

[Qs Laptop]

New Medicare recipient here. I'm on my state's equivalent plan to Medicare Supplement plan N. I went with Cigna as my insurance company and got this plan set up through Boomer Benefits.

So far I've seen two doctors--a urologist that I'd been seeing prior to Medicare and my primary care physician for my "Welcome to Medicare" visit.

The urologist visit ended up costing me $107.78, I guess this amount was applied to the annual $226 deductible. I paid the $107.78 out of pocket. The PCP visit for Welcome to Medicare was billed to me for $570. That's not right. Even though when I made the appointment I told scheduling this was to be my Welcome to Medicare preventative visit (apparently) they didn't code it correctly.

No problem, I simply called up Boomer Benefits told them my story and after emailing them copies of my invoice they called the care provider on my behalf and got the medical billing codes changed so I ended up paying nothing for the PCP visit.

My current urologist is now talking about surgery and wants me to schedule a consultation with him. The earliest I can see him is January. I've decided I want to see a different urologist. I'm going to explain my treatment history and ask for an assessment of my past treatment plan and also ask about whether or not surgery might be indicated.

What should I tell the new urologist's office is the purpose of my visit in order to get Medicare to cover it?

 

[REWahoo]

What should I tell the new urologist's office is the purpose of my visit in order to get Medicare to cover it?

Tell them this:

I'm going to explain my treatment history and ask for an assessment of my past treatment plan and also ask about whether or not surgery might be indicated.

If the urologist accepts Medicare assignment, then they should know the proper codes to use to bill Medicare.

 

[Qs Laptop]

If the urologist accepts Medicare assignment, then they should know the proper codes to use to bill Medicare.

Yes, I presumed the same with my "Welcome to Medicare" visit.

I got the name of the new urologist from Cigna's site. Cigna says this urologist follows Medicare billing guidelines, the urologist's websites also says this and the scheduler confirmed it as well. So, I would think they would get it correct.

For any other potential future office visits is there any general advice you can give regarding medical codes and Medicare?

 

[OldShooter]

... I got the name of the new urologist from Cigna's site. ...

CIGNA's goals in selecting doctors are unlikely to be the same as yours. Suggest you run the name by your PCP for an opinion, maybe ask for a recommendation. I also suggest you check to see whether the PCP and the urologist you choose are using the same record-keeping software. That will improve the efficiency of your care and possibly reduce errors. The most popular software is Epic.

 

[REWahoo]

For any other potential future office visits is there any general advice you can give regarding medical codes and Medicare?

I don't think you need to have any concerns about future coding issues as my experience is they are relatively rare.

DW and I have 10+ years of Medicare coverage and have only had one instance of a coding error, which was early on and also associated with a "Welcome to Medicare" visit. Zero issues since.

 

[Qs Laptop]

CIGNA's goals in selecting doctors are unlikely to be the same as yours. Suggest you run the name by your PCP for an opinion, maybe ask for a recommendation.

I've asked my PCP about a urologist. He's in the ParkNicollet/HealthPartner provider system. He did suggest another ParkNicollet urologist but this guy is also booked through January.

I also suggest you check to see whether the PCP and the urologist you choose are using the same record-keeping software. That will improve the efficiency of your care and possibly reduce errors. The most popular software is Epic.

My PCP (ParkNicollet) uses MyChart. The new urologist uses something else. Other than asking them, any tips for determining if the new urologist's software is Epic? It says AthenaHealth on the sign in screen.

I think I can figure out a way to download most of the data on MyChart and bring it along with me to the new urologist.

 

[OldShooter]

I've asked my PCP about a urologist. He's in the ParkNicollet/HealthPartner provider system. He did suggest another ParkNicollet urologist but this guy is also booked through January.

There may be a reason for that.

My PCP (ParkNicollet) uses MyChart.

That's the name of Epic's patient portal. So they are running Epic.

The new urologist uses something else. Other than asking them, any tips for determining if the new urologist's software is Epic? It says AthenaHealth on the sign in screen.

From some quick searches, I think that is a different system. You might call the new provider and ask if their system can exchange information with Epic.

I think I can figure out a way to download most of the data on MyChart and bring it along with me to the new urologist.

IMO the issue is more long term. Medication lists on two different systems, for example, mean both doc's nurses will ask you every time to verify their list, which may be incomplete. Epic can also show history graphs of things like blood pressure, PSA, etc. but only from the data points that it has. Presumably AthenaHealth can do the same, but again only using the data that it has. I go through this with my dental clinic, whose software doesn't seem to be compatible with anything. They take a blood pressure on every visit, none of which every finds its way to my PCP. Meds, the same problem, they are always asking me to verify their meds list.

I am not a medical person, so I can't evaluate how important compatible systems might be, but being trained as a scientise and engineer I know that working with an incomplete dataset is a bad idea. Maybe your PCP can offer an opinion.

 

[Qs Laptop]

I am not a medical person, so I can't evaluate how important compatible systems might be, but being trained as a scientise and engineer I know that working with an incomplete dataset is a bad idea. Maybe your PCP can offer an opinion.

I have an engineering background and used to work with/for scientists so I understand the need to have complete data sets and the ability to easily transfer it. However, while it is a factor in choosing a physician for me it's not going to be the primary factor.

 

[RetMD21]

Yes, I presumed the same with my "Welcome to Medicare" visit.

I got the name of the new urologist from Cigna's site. Cigna says this urologist follows Medicare billing guidelines, the urologist's websites also says this and the scheduler confirmed it as well. So, I would think they would get it correct.

Well, they're legally obligated to follow Medicare rules. Although you would think they would get it right there are a lot of medical billing errors but they aren't really your responsibility.

 

[MRG]

My first year on Medicare was goofy because I paid a partial deductible to a provider before the billing cycle was complete. Then deductibles and refunds were finally figured out 6 months later.

Now I refuse to pay any deductibles until they bill Medicare and tell me what they did.

As a retired software developer, I don't care what stack my doctor uses.

 

[Gotadimple]

The #1 thing you should never do, is pay the provider before your insurance has issued the EOB. If they match then pay the invoice, if not, call the provider and ask them to review their billing because "Cigna says I only owe you ..."

For your urologist visit, it seems that these providers in your area are booked up until January. This gives you time to other research. Double-check if your plan N requires any referrals to specialists, and if they do, because you are asking for a second opinion, ask your PCP to refer to that specific provider. Hopefully, they can refer out of their clinic network.

 

[RetMD21]

Double-check if your plan N requires any referrals to specialists, and if they do, because you are asking for a second opinion, ask your PCP to refer to that specific provider. Hopefully, they can refer out of their clinic network.

Unless it's a Medicare Select supplement the network should be all medicare providers, right?

 

[jgrdarrash]

Lots of threads on the problems with "Welcome to Medicare " and "Annual Wellness Visits". If you talk about anything outside the Very Narrow list of topics allowed on those visits it goes from being a "Wellness" visit to a diagnostic visit. So if you mentioned anything about your urological problems or any other issue they have to change the code.
As for the EMR (electronic medical records) you can try to ask if their Athena chart will share with EPIC but it's unlikely the office staff will know for sure. It's certainly more convenient and safer for all clinicians to be on one system like EPIC. But not always feasible. You can ask to be put on the wait list for the urologist if there's a cancellation before January.

 

[target2019]

You have to wait a year before getting the wellness checkup. Ask me how I know?

 

[teej1985]

No problem, I simply called up Boomer Benefits told them my story and after emailing them copies of my invoice they called the care provider on my behalf and got the medical billing codes changed so I ended up paying nothing for the PCP visit.

Sounds like that's a nice benefit of using a broker! But Shame on them for selling Cigna who is one of the insurers notorious for closing pools and opening new ones.

 

[Gotadimple]

Unless it's a Medicare Select supplement the network should be all medicare providers, right?

Assuming your Plan N operates like a Plan N available to the public, you have to ask the provider if they work with Medicare. If your Plan N gives you a list of providers, then, those providers are contracted with your corporate plan and they accept Medicare.

 

[Gotadimple]

Sounds like that's a nice benefit of using a broker! But Shame on them for selling Cigna who is one of the insurers notorious for closing pools and opening new ones.

Insurers can and do open and close plans. The agent cannot keep up with all the carriers opening and closing plans. I am pretty sure Boomer Benefits recommended Cigna because it had the best coverage and price for the OP's situation.

 

[RetMD21]

Insurers can and do open and close plans. The agent cannot keep up with all the carriers opening and closing plans. I am pretty sure Boomer Benefits recommended Cigna because it had the best coverage and price for the OP's situation.

Coverage is the same for all plan Ns (except select)

 

[teej1985]

Insurers can and do open and close plans. The agent cannot keep up with all the carriers opening and closing plans. I am pretty sure Boomer Benefits recommended Cigna because it had the best coverage and price for the OP's situation.

Coverage is uniform. All plan Ns offer the same coverage. The Senior Savings Network seems to recommend plans that play the open-and-close game also. Perhaps the majority of insurers who sell through brokers do this, and the brokers choose to be ignorant to it.

 

[Gotadimple]

Coverage is uniform. All plan Ns offer the same coverage.

True, but the OP is on a state-sponsored version of Plan N (see post #1). So it's a retiree benefit and may have been changed from the standard Plan N offerings.

The Senior Savings Network seems to recommend plans that play the open-and-close game also. Perhaps the majority of insurers who sell through brokers do this, and the brokers choose to be ignorant to it.

Brokers that serve a specific market (individuals, Medicare for example) focus on sales because they need to make so many contacts before even one sale is recorded. They can spend their time limiting the number of carriers to those that don't open and close products, or they can meet with potential clients and help them choose a product from a wide range of offerings.

It is one thing to look down on insurers who open and close products but that ignores the need to be financially stable as an insurance carrier. If they keep selling products that are losing money because they can't change the coverage and premium increases would kill the product, it is in your best interest that they close the product to new members.

It is no different than a bank making loans when it doesn't have deposits. At some point, the financial impact shows up on the Insurance Commissioners' desk and their whole operation is shut down. Then you have to find a new insurer to replace what you bought.

-Rita

 

[teej1985]

True, but the OP is on a state-sponsored version of Plan N (see post #1). So it's a retiree benefit and may have been changed from the standard Plan N offerings.

No. OP bought an individual plan from Boomer Benefits. His state doesn't use the standardized letter plans. His state calls them something different, but they are the same.

 

[RetMD21]

No. OP bought an individual plan from Boomer Benefits. His state doesn't use the standardized letter plans. His state calls them something different, but they are the same.

Right, I think it's MA, MN and WI.

 

[teej1985]

Brokers that serve a specific market (individuals, Medicare for example) focus on sales because they need to make so many contacts before even one sale is recorded. They can spend their time limiting the number of carriers to those that don't open and close products, or they can meet with potential clients and help them choose a product from a wide range of offerings.

It is one thing to look down on insurers who open and close products but that ignores the need to be financially stable as an insurance carrier. If they keep selling products that are losing money because they can't change the coverage and premium increases would kill the product, it is in your best interest that they close the product to new members.

It is no different than a bank making loans when it doesn't have deposits. At some point, the financial impact shows up on the Insurance Commissioners' desk and their whole operation is shut down. Then you have to find a new insurer to replace what you bought.

-Rita

That's all fine and good, but consumers need to look out for themselves and do the research, not blindly trust a broker. Some insurers have figured out how to make profits and not play the open-and-close game.

If you live in a state that does not have a birthday rule or some other open enrollment rule, you might be stuck with your initial choice for multiple decades. You don't want to end up that person.

 

[RetMD21]

Some insurers have figured out how to make profits and not play the open-and-close game.

If you live in a state that does not have a birthday rule or some other open enrollment rule, you might be stuck with your initial choice for multiple decades. You don't want to end up that person.

Being stuck in a plan makes Medigap different. At least one insurer has "closed the book" and substantially raised formerly attractive rates while opening a new "book" with lower rares. Telly posted about his experiences in 2019


https://www.early-retirement.org/fo...-provider-selection-for-my-plan-g-100099.html

 

[teej1985]

Being stuck in a plan makes Medigap different. At least one insurer has "closed the book" and substantially raised formerly attractive rates while opening a new "book" with lower rares. Telly posted about his experiences in 2019


https://www.early-retirement.org/fo...-provider-selection-for-my-plan-g-100099.html

Mutual of Omaha, Aetna and Cigna are notorious for this. It's mentioned over and over in this and other forums, but people either don't see the threads or ignore them. One person had this fear that other companies could do the same thing, and picked one of these companies because of that fear - yet these companies have the track record or doing it. Makes no sense.