Please explain how Medicare Billing works?

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Lynette
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Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 2:28 pm

I have just joined Medicare B and I have Medigap B from AARP United Health Care. From what I understand one is entitled to a Welcome to Medicare within the first twelve months. I have received a notice from Medicare that my Annual Wellness test was denied. There is a note on the claim form that Medicare does not cover an Annual Wellness Test within the 12 months of your Medicare B coverage. Medicare does cover a one-time Welcome to Medicare Preventive visit within the first 12 months.

What is going on here? I went for the Welcome to Medicare Preventive visit. Was there an incorrect billing code by my doctor's office? Do I call the doctor's office, Medicare?

I will try not to express frustration - Medicare B premium $270 per month and nearly $200 for Medigap B. It's better to die than to deal with this! My doctor said he'd see me next time - no problems.

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Sun Jun 04, 2017 2:36 pm

I hope for your sake this is not that UHC AARP "Secure Horizons" plan. Denial is the name of the game.

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SpringMan
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Re: Please explain how Medicare Billing works?

Postby SpringMan » Sun Jun 04, 2017 2:44 pm

Higher income means higher rates for medicare. Currently the cutoff is $170,000 for filing joint and $85,000 otherwise. If an EOB is wrong call your doctor's office.
https://www.ssa.gov/pubs/EN-05-10536.pdf
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Pajamas
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Re: Please explain how Medicare Billing works?

Postby Pajamas » Sun Jun 04, 2017 2:46 pm

Basically, you get the "Welcome to Medicare" preventive visit one time and only within twelve months of signing up for part B and then the "Annual Wellness Visit" is a yearly follow-up to that initial assessment.

Both are for assessment and planning rather than treatment of existing conditions. Since they are basically the same thing, you can't have both in the same year.

https://www.medicare.gov/coverage/preve ... exams.html

Your doctor's office may have billed it incorrectly. Contact them and explain what happened.

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nisiprius
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Re: Please explain how Medicare Billing works?

Postby nisiprius » Sun Jun 04, 2017 2:55 pm

In four years on Medicare A, B, and Medicare Supplemental (Medigap) I have yet to have a medical office actually try to bill me. I have gotten occasional notices about claims denials but they get batted back and forth between the provider and Medicare, and they've always worked it out between themselves without involving me other than sending me notices. Medicare Supplemental is not much of a problem because the insurer does not really have any decisions to make approvals, Medicare does that before they get the bill.
Annual income twenty pounds, annual expenditure nineteen nineteen and six, result happiness; Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.

Grasshopper
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Re: Please explain how Medicare Billing works?

Postby Grasshopper » Sun Jun 04, 2017 4:18 pm

I had this happen, my billing was for annual at 9 months into MC by my GP, I called they billed it as welcome, all is good.

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Sun Jun 04, 2017 4:41 pm

What CPT code was billed on your EOB?
And did your visit address any existing health conditions?

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 4:58 pm

toofache32 wrote:What CPT code was billed on your EOB?
And did your visit address any existing health conditions?


Thanks for the replies. I decided that I was not going to take any chances so I sent a reply to Medicare asking why my claim was denied, I copied my doctor and UHC. The end of May was my first visit to a doctor since I became eligible for Medicare at the beginning 2017. I will leave them to figure it out. I'm still irritated at having to pay Medicare B and D IRMAA rates. I worked and paid all my taxes until I was 73 so that I would have decent pensions. I do have decent pensions but Medicare wants more from me. The only slight issue I have is high cholesterol that is controlled my medication. I reluctantly agreed to take the statin drug as there is no history of heart disease in my family and my blood pressure is low.

My employer required the health providers to send employees for an annual wellness test. Last year those of us who were considered healthy were exempted. Yesterday I cut down a tree with a chainsaw and then lugged 40 bags of soils and mulch from Home Depot to cover that area. So I'm fortunate at 73 to still be in really good health.

Big Dog
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Re: Please explain how Medicare Billing works?

Postby Big Dog » Sun Jun 04, 2017 5:14 pm

I worked and paid all my taxes


Don't forget that the payroll taxes (FICA) only cover Part A, not Part B, which is funded by annual congressional appropriations and you, the user.

Be thankful that you are still in good health. (I have a yard in SoCal that could use some mulching!)

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Sun Jun 04, 2017 5:31 pm

What CPT code was billed on your EOB?
And did your visit address any existing health conditions?

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 5:32 pm

Big Dog wrote:
I worked and paid all my taxes


Don't forget that the payroll taxes (FICA) only cover Part A, not Part B, which is funded by annual congressional appropriations and you, the user.

Be thankful that you are still in good health. (I have a yard in SoCal that could use some mulching!)


Wherever the money comes from, there is no tax incentive to work beyond 65. I've seen tax proposals to encourage seniors to work longer.

As for the mulching ... :D, I live in Michigan. I will have a lot more delivered by a supplier. Now that I am retired, I can fix up my yard. I had lawn between the garage and fence. The lawn service guys could not use a mower there so they used a cutter and made a mess of the vinyl siding of my garage. Handyman will replace the bottom slats .. and I'll put down more mulch!

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FrugalInvestor
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Re: Please explain how Medicare Billing works?

Postby FrugalInvestor » Sun Jun 04, 2017 5:41 pm

toofache32 wrote:What CPT code was billed on your EOB?
And did your visit address any existing health conditions?


I'm curious about this as well. Hope you'll answer toofache32 so I can see the response.
IGNORE the noise! | Our life is frittered away by detail... simplify, simplify. - Henry David Thoreau

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 5:44 pm

toofache32 wrote:What CPT code was billed on your EOB?
And did your visit address any existing health conditions?


EOB? What is that? Sorry, I'm still new to this. The letter said that this is not a bill and specified the amount my doctor could bill me. This was $293.85

Under Service provided it states:

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit (G0439).

I was given a prescription to a hospital for a mammogram that I did not have since 2015 as well as a bone density test. The latter isn't that great but I'm not on medication for it. I've been seeing the same doctor for about 15 years and this is the first time I'm on Medicare. The doctor's office told me that this visit would be fully covered.

They also took blood tests and I got a letter saying that everything was fine and the doctor would see me next year. Previously when I was still employed and we had to go for annual wellness test, the HMO paid 100% of it.
Last edited by Lynette on Sun Jun 04, 2017 5:58 pm, edited 1 time in total.

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dodecahedron
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Re: Please explain how Medicare Billing works?

Postby dodecahedron » Sun Jun 04, 2017 5:58 pm

I agree you should answer toofache's question and tell us the code on your EOB.

My theory is that your doctor's office staff (whoever coded the claim filed with Medicare) could not conceive of the possibility that a 73-year-old was "new to Medicare" and coded the record as an annual wellness visit rather than as an initial "Welcome to Medicare" visit. Most Medicare participants are enrolled long before age 73. It should be easy to set them straight and have them refile the claim with a correct coding.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 6:00 pm

dodecahedron wrote:I agree you should answer toofache's question and tell us the code on your EOB.

My theory is that your doctor's office staff (whoever coded the claim filed with Medicare) could not conceive of the possibility that a 73-year-old was "new to Medicare" and coded the record as an annual wellness visit rather than as an initial "Welcome to Medicare" visit. Most Medicare participants are enrolled long before age 73. It should be easy to set them straight and have them refile the claim with a correct coding.


Hi dodecahedron, as mentioned the only code I can find is (G0439).

MPAndy222
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Re: Please explain how Medicare Billing works?

Postby MPAndy222 » Sun Jun 04, 2017 6:06 pm

It looks like they billed it as an annual medicare wellness (G0439) instead of welcome to medicare exam (G0402). The welcome to medicare exam includes EKG, vision check, and hearing screen in addition to the normal annual medicare wellness questions. If they drew blood work then they needed to add a modifier for it to be covered. I would contact the physician's office as they will likely need to resubmit the correct coding

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dodecahedron
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Re: Please explain how Medicare Billing works?

Postby dodecahedron » Sun Jun 04, 2017 6:15 pm

I didn't see your post with the code until after I'd submitted mine, but yes, my theory seems to be confirmed. Whoever did the claim filing at your doc's office likely didn't realize you were in your first year of Medicare coverage and so they coded it incorrectly. (Billing and claim filing is often done by back office people who may be in a completely separate environment from your physician's office.)

To answer your question, EOB stands for "Explanation of Benefits," and that is the statement that any insurance company sends you and your provider after a claim has been submitted.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 6:26 pm

MPAndy222 wrote:It looks like they billed it as an annual medicare wellness (G0439) instead of welcome to medicare exam (G0402). The welcome to medicare exam includes EKG, vision check, and hearing screen in addition to the normal annual medicare wellness questions. If they drew blood work then they needed to add a modifier for it to be covered. I would contact the physician's office as they will likely need to resubmit the correct coding


Thanks Andy and everyone who replied. As I'm new to Medicare, I was concerned as the letter stated that I had to appeal by a certain date. I copied the Doctor's office, Medicare and UHC.

Another question, please. If there is an amount to be paid, will the doctors office submit it to UHC (Medigap F) first or does it come directly to me and I have to send it to UHC?

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Re: Please explain how Medicare Billing works?

Postby MPAndy222 » Sun Jun 04, 2017 6:29 pm

Lynette wrote:
MPAndy222 wrote:It looks like they billed it as an annual medicare wellness (G0439) instead of welcome to medicare exam (G0402). The welcome to medicare exam includes EKG, vision check, and hearing screen in addition to the normal annual medicare wellness questions. If they drew blood work then they needed to add a modifier for it to be covered. I would contact the physician's office as they will likely need to resubmit the correct coding


Thanks Andy and everyone who replied. As I'm new to Medicare, I was concerned as the letter stated that I had to appeal by a certain date. I copied the Doctor's office, Medicare and UHC.

Another question, please. If there is an amount to be paid, will the doctors office submit it to UHC (Medigap F) first or does it come directly to me and I have to send it to UHC?


It should automatically go to the medicare advantage plan (medigap F) as long as the doctor's office appropriately lists it as a secondary

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dratkinson
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Re: Please explain how Medicare Billing works?

Postby dratkinson » Sun Jun 04, 2017 6:42 pm

Within past year, received a Medicare notice saying claim for an exam had been denied.
Called Medicare. Got a human surprisingly fast.
Human said claim had already been resolved and doctor paid.

Human said Medicare paperwork is only mailed quarterly, and only then if you have a claim during the quarter.
So Medicare paperwork was just slow and didn't reflect most recent update.

Assumed doctor's staff corrected claim to use the right magic code number.

Give it time as issue will probably be resolved without your intervention.
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Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jun 04, 2017 7:52 pm

dratkinson wrote:Within past year, received a Medicare notice saying claim for an exam had been denied.
Called Medicare. Got a human surprisingly fast.
Human said claim had already been resolved and doctor paid.

Human said Medicare paperwork is only mailed quarterly, and only then if you have a claim during the quarter.
So Medicare paperwork was just slow and didn't reflect most recent update.

Assumed doctor's staff corrected claim to use the right magic code number.

Give it time as issue will probably be resolved without your intervention.


Thanks - just letting things go is likely best but not my style and I still have low blood pressure! I opened the letter this afternoon. I typed a response, had it copied and sent letter with attachments to Medicare copying doctor and Medigap. Took about two hours - letters are in the mail. This way I'm covered and I have a copy of the letter.

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Re: Please explain how Medicare Billing works?

Postby mouses » Sun Jun 04, 2017 8:05 pm

Lynette wrote:I will try not to express frustration - Medicare B premium $270 per month and nearly $200 for Medigap B. It's better to die than to deal with this! My doctor said he'd see me next time - no problems.


I'm getting confused by all these B's floating around. Do you mean Medicare Plan B costs you $270 a month and Medigap Plan B costs you $200 a month? I have the same cost for Medigap Plan F but Medicare Plan B for me is $110 a month. Are you being charged more due to high income or something?

The premiums seem like a lot of money, but wait until you get older and start burning through five figures easily in medical costs a year.

Except for occasional coding errors, my experience is that Medicare plus Medigap is hands off the wheel for the patient. Your Plan B won't be quite like that, but pretty close. Medicare pays part of the bill, sends the remainder of the bill to your Medigap provider, and you never have to worry your head about it.

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Re: Please explain how Medicare Billing works?

Postby nisiprius » Sun Jun 04, 2017 8:25 pm

I can't say how it works for anyone else... and all insurance is governed by state laws and varies a lot from state to state...

...no, I don't get a bill. I don't need to file claims with my Medigap insurance company myself. So far it's all been smooth and automatic.

What happens with me is that the provider bills Medicare. Medicare decides whether or not to approve the service. If they approve it, they then decide on the amount to approve. If it is a Part B (doctor, not hospital) service, they then pay 80% of that amount. Eventually, a long time later, I get a mailed statement, a Medicare Summary Notice from the Center for Medicare Services, saying something like:

Service Approved: Yes
Amount Provider Charged: $300
Medicare-Approved Amount: $100
Amount Medicare Paid: $80
MAXIMUM YOU MAY BE BILLED: $20.

But I do not get billed. Medicare bills my Medigap insurance company the $20 automatically. They pay. In due course I get another notice from my Medigap insurance company saying so.

The astonishing difference between the $300 charge and the $100 that is approved is typical of all insurance, but you don't always the bill that shows it. The provider charges a crazy-high rate, sometimes called the "chargemaster" rate, the insurer pays a much lower negotiated rate... and the provider is contractually obliged to accept. In the case of Medicare, a provider who "accepts Medicare assignment" is required to accept the Medicare-approved amount in full payment.

So far, it's all been very smooth.
Annual income twenty pounds, annual expenditure nineteen nineteen and six, result happiness; Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.

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Re: Please explain how Medicare Billing works?

Postby dennisbyron » Mon Jun 05, 2017 6:44 am

Mouses, you wrote:

I'm getting confused by all these B's floating around. Do you mean Medicare Plan B costs you $270 a month and Medigap Plan B costs you $200 a month? I have the same cost for Medigap Plan F but Medicare Plan B for me is $110 a month. Are you being charged more due to high income or something


Yes, the original writer mentioned somewhere that he or she was paying more because of "high" income (in 2015, I think is the way it works but maybe in 2016). That person might win an appeal on the grounds that the high income two years ago was because he or she was working and that won't happen every year.

But even if the person was to make such an appeal and win, he or she would pay the 2017 rate of $134 a month for Part B, not the about $110 you and I pay. We pay less because of a thing in the Social Security law called "hold harmless," which says our monthly Part B premium cannot go up more than our SS benefit.

(Also the fact that you are paying the same amount as the original commenter for private Medigap insurance is either pure coincidence or you live the same state as the original commenter, are possibly the same age, and selected the same insurance company. Private Medigap plans vary widely in price and availability state to state and by insurance company and in some states they can be age rated (as well as denied for pre-existing conditions except when first signing up for Medicare).)

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Mon Jun 05, 2017 8:20 am

mouses wrote:
Lynette wrote:I will try not to express frustration - Medicare B premium $270 per month and nearly $200 for Medigap B. It's better to die than to deal with this! My doctor said he'd see me next time - no problems.


I'm getting confused by all these B's floating around. Do you mean Medicare Plan B costs you $270 a month and Medigap Plan B costs you $200 a month? I have the same cost for Medigap Plan F but Medicare Plan B for me is $110 a month. Are you being charged more due to high income or something?

The premiums seem like a lot of money, but wait until you get older and start burning through five figures easily in medical costs a year.

Except for occasional coding errors, my experience is that Medicare plus Medigap is hands off the wheel for the patient. Your Plan B won't be quite like that, but pretty close. Medicare pays part of the bill, sends the remainder of the bill to your Medigap provider, and you never have to worry your head about it.


Yes, I have to pay an additional premium for both Medicare B and D as I have pensions and full Social Security. I think the premiums I pay for both B and D are about $300 a month. I have to pay extra as it is means tested - it is difficult to escape this additional charge if one has pensions. On top of this I pay $200 for Medigap F. So this is $500 a month. I was paying about $160 in a month while employed.

So far, I'm extremely frustrated with Medicare. I don't fit the norm as I worked till 73 instead of retiring at 65. I had to fill in additional paperwork to get Medicare B. I had to prove that I had medical insurance from 65 to 73. Due to mistakes on both my employers side and lack of understanding on Social Security side, it took me nearly four months to resolve this. Now there is obviously another problem as my doctor's office seems to have given the incorrect billing code.

I know that medical insurance is a requirement but if my health is as good as my mother's, my major medical expense is these incessant test to which I subject myself - wellness, mammograms, bone density etc. Usually, the response is - all clear - see you next year.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Mon Jun 05, 2017 9:05 am

nisiprius wrote:I can't say how it works for anyone else... and all insurance is governed by state laws and varies a lot from state to state...

...no, I don't get a bill. I don't need to file claims with my Medigap insurance company myself. So far it's all been smooth and automatic.

What happens with me is that the provider bills Medicare. Medicare decides whether or not to approve the service. If they approve it, they then decide on the amount to approve. If it is a Part B (doctor, not hospital) service, they then pay 80% of that amount. Eventually, a long time later, I get a mailed statement, a Medicare Summary Notice from the Center for Medicare Services, saying something like:

Service Approved: Yes
Amount Provider Charged: $300
Medicare-Approved Amount: $100
Amount Medicare Paid: $80
MAXIMUM YOU MAY BE BILLED: $20.

But I do not get billed. Medicare bills my Medigap insurance company the $20 automatically. They pay. In due course I get another notice from my Medigap insurance company saying so.

The astonishing difference between the $300 charge and the $100 that is approved is typical of all insurance, but you don't always the bill that shows it. The provider charges a crazy-high rate, sometimes called the "chargemaster" rate, the insurer pays a much lower negotiated rate... and the provider is contractually obliged to accept. In the case of Medicare, a provider who "accepts Medicare assignment" is required to accept the Medicare-approved amount in full payment.

So far, it's all been very smooth.


Nisiprius, thank you very much for the detailed explanation - much appreciated.

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Re: Please explain how Medicare Billing works?

Postby kaneohe » Mon Jun 05, 2017 9:57 am

nisiprius wrote:In four years on Medicare A, B, and Medicare Supplemental (Medigap) I have yet to have a medical office actually try to bill me. I have gotten occasional notices about claims denials but they get batted back and forth between the provider and Medicare, and they've always worked it out between themselves without involving me other than sending me notices. Medicare Supplemental is not much of a problem because the insurer does not really have any decisions to make approvals, Medicare does that before they get the bill.


Don't underestimate the powers of humans to muck things up. :D Been on Medicare /Medigap for 9 yrs and experience until recently was like yours....never have to worry about details, let the 3 parties....Medicare/Medigap/Provider duke it out. Recently got a bill for over $500 from
provider. Have had multiple similar bills and no problem. This time, however, gross charge is the same . Medicare/Medigap report the same adjusted Medicare charge and basically that Medicare pays 80%/Medigap pays 20% w/ 0 billing to me. Yet provider insists I own $500+ and that it will take 30-60 days to review.

Finally called to talk to supervisor. At least, at that level, they can think a bit. Asked why if charges $650, payments/adjustment 150, amount
I need to pay 500, why is payment due 550? Stumped her. Then I asked where the payments/adjustments number came from......turns out somebody at provider's office forgot to include the Medicare writedown of charges as an adjustment. Poof, bill vanished. Problem solved for now.

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Re: Please explain how Medicare Billing works?

Postby mouses » Thu Jun 08, 2017 5:10 pm

nisiprius wrote:Amount Provider Charged: $300
Medicare-Approved Amount: $100
Amount Medicare Paid: $80
MAXIMUM YOU MAY BE BILLED: $20.

But I do not get billed. Medicare bills my Medigap insurance company the $20 automatically. They pay. In due course I get another notice from my Medigap insurance company saying so.

The astonishing difference between the $300 charge and the $100 that is approved is typical of all insurance, but you don't always the bill that shows it. The provider charges a crazy-high rate, sometimes called the "chargemaster" rate, the insurer pays a much lower negotiated rate... and the provider is contractually obliged to accept. In the case of Medicare, a provider who "accepts Medicare assignment" is required to accept the Medicare-approved amount in full payment.

So far, it's all been very smooth.


I have never understood what is going on wrs this. When I see what Medicare plus Medigap pay my doctor vs what the doctor asks for, I think the practice must be on the verge of bankruptcy. What is the rational behind the crazy-high rate? Do they think that will influence Medicare at some point to pay more?

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Re: Please explain how Medicare Billing works?

Postby toofache32 » Thu Jun 08, 2017 11:05 pm

mouses wrote:
nisiprius wrote:Amount Provider Charged: $300
Medicare-Approved Amount: $100
Amount Medicare Paid: $80
MAXIMUM YOU MAY BE BILLED: $20.

But I do not get billed. Medicare bills my Medigap insurance company the $20 automatically. They pay. In due course I get another notice from my Medigap insurance company saying so.

The astonishing difference between the $300 charge and the $100 that is approved is typical of all insurance, but you don't always the bill that shows it. The provider charges a crazy-high rate, sometimes called the "chargemaster" rate, the insurer pays a much lower negotiated rate... and the provider is contractually obliged to accept. In the case of Medicare, a provider who "accepts Medicare assignment" is required to accept the Medicare-approved amount in full payment.

So far, it's all been very smooth.


I have never understood what is going on wrs this. When I see what Medicare plus Medigap pay my doctor vs what the doctor asks for, I think the practice must be on the verge of bankruptcy. What is the rational behind the crazy-high rate? Do they think that will influence Medicare at some point to pay more?


Everyone gets "billed" the same amount. But if the doctor is in-network with the patient's insurance then they contractually must accept the lower insurance reimbursement from the insurance as payment in full. Uninsured patients do not have such a contract with the doctor. Most insurance contracts require doctors to bill uninsured patients the same high amount as they bill insured patients. This is by design because the insurance companies use their contracts with doctors to make uninsured patients think "wow I need insurance" and drive more customers to the insurance company.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Wed Jun 21, 2017 6:35 pm

What a terrible system! Medicare denied my appeal - more paperwork. So now I have to appeal again!!! I pay $500 a month compared to $160 and I cannot even go for preventive tests at the age of 73. Oh well - everyone likes Medicare - except for me.

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Hondo
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Re: Please explain how Medicare Billing works?

Postby Hondo » Wed Jun 21, 2017 7:37 pm

Sounds like the same thing that happened to me. Went to my doctor for my annual visit within 1 year of going on Medicare. The doctor coded this as my "Annual Wellness" visit rather than "Welcome to Medicare." Medicare denied the claim because the "Annual Wellness" visit can only occur after you have been on Medicare for a year. I informed the doctor's office what had happened and that it needed to be recoded to "Welcome to Medicare". They did so, and that took care of the matter with Medicare paying in full.

If this is what happened to you, then an appeal to Medicare will not help. Medicare made the correct decision based on what the doctor submitted. The mistake was made by the doctor's office, and Medicare cannot change the coding. You will need to get your doctor's office to recode the visit and resubmit to Medicare. From what I hear this is a fairly common problem when folks first enroll in Medicare.

Other than this situation, which was promptly remedied, I've had no problems with Medicare.

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Re: Please explain how Medicare Billing works?

Postby kaneohe » Wed Jun 21, 2017 8:08 pm

Sorry for the agony you are going through. Medicare plus Medigap is supposed to be a hands-off self-running system unless, as others have said, the coding is wrong. I'm surprised your BP is still under control. Perhaps your best weapon is to get a sympathetic supervisor at the doctor's office and let that person know that you are both in the same boat. If Medicare doesn't approve/pay, the same will happen w/ Medigap. You want the doctor to be compensated for the work but you are not going to pay (since Medicare/Medigap is supposed to) and consequently ,the doctor will not be paid either.
The supervisor should understand the critical role their team plays in the big picture and try to make things right. If they threaten you instead w/
collections, then you have the wrong person and should try to find someone else.

You should be the general directing the team even tho you may not have the detailed knowledge about coding,etc.
You should not be doing all the grunt work of appealing,etc. The latter sounds like an ulcer-inducing practice.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Wed Jun 21, 2017 8:18 pm

I called the billing department at my doctor's office and got a voicemail. I think that they don't work on a Wednesday. I left an irritated message for them to get the billing code correct! As I am frustrated, I decided to do a formal appeal. I am writing a letter telling them that the billing code may be incorrect. I am also including details of the preventive screening that I had to undertake.

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HueyLD
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Re: Please explain how Medicare Billing works?

Postby HueyLD » Thu Jun 22, 2017 10:17 am

Lynette wrote:I called the billing department at my doctor's office and got a voicemail. I think that they don't work on a Wednesday. I left an irritated message for them to get the billing code correct! As I am frustrated, I decided to do a formal appeal. I am writing a letter telling them that the billing code may be incorrect. I am also including details of the preventive screening that I had to undertake.

Coding problems happen more often than you think, even for those not on Medicare.

I think a lot of practices outsource their billing to some third party corporation and it could be a nightmare if one needs to have billing errors corrected. I have been down that road before and neither the practice nor the billing department would return my phone calls. Even writing polite letters to supervisors didn't get any reply from either.

So, a proactive formal appeal may be the only option for the OP. Hang in there and best of luck to you.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 12:16 pm

Thanks. I sent an appeal copying doctor's office, and AARP - 13 pages in all. Incidentally the doctor's office told me that I would not be billed.They would have to bill me. I have been a patient of theirs for about 20 years. I could always go and see the doctor's office as they are only about three miles from me if they do not return my call - not bothering with them for now - following formal process.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 12:25 pm

I decided that this was total nonsense. The doctor's office told me I would not be billed. I called again but got a voicemail. I will give them a day or two to get my appeal and then I will go and encamp on their doorstep and make a polite fuss.

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dm200
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Re: Please explain how Medicare Billing works?

Postby dm200 » Thu Jun 22, 2017 12:39 pm

Add this narrative/discussion to my list of why my wife and I are very happy participants in the Kaiser Medicare Plan for this area. Close to zero billing issues/errors and prompt explanation/resolution for a small occasional "burp". I suspect such "aggravation" as described here is probably not good for one's health.

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BL
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Re: Please explain how Medicare Billing works?

Postby BL » Thu Jun 22, 2017 1:06 pm

Just want to add that there is probably not only a co-payment but a deductible amount for each year with Medicare and, I suspect, your supplement policy. That would also show up with the first visit of the year.
Part B deductible $183 per year

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nisiprius
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Re: Please explain how Medicare Billing works?

Postby nisiprius » Thu Jun 22, 2017 1:19 pm

Pssst. By the way. Apple, penny, table. Also, DEFPOTEC.
Annual income twenty pounds, annual expenditure nineteen nineteen and six, result happiness; Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 1:53 pm

BL wrote:Just want to add that there is probably not only a co-payment but a deductible amount for each year with Medicare and, I suspect, your supplement policy. That would also show up with the first visit of the year.
Part B deductible $183 per year


I have Medigap F - do I still have a deductible?

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 1:56 pm

nisiprius wrote:Pssst. By the way. Apple, penny, table. Also, DEFPOTEC.



????

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Thu Jun 22, 2017 2:05 pm

Lynette wrote:
nisiprius wrote:Pssst. By the way. Apple, penny, table. Also, DEFPOTEC.



????


I'm just as confused.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 2:13 pm

Maybe it is not a billing code issue. In the letter why the request was rejected it states:

"Medicare will make payment for a Medicare Physical Exam when all the requirements are met. This is a one-time exam within the first 12 months that you have Part B. Your exam should include a review of your health, information about the service you need, like screenings and shots, and referrals for other care. We show that you did not have a screening and shots and therefore, your doctor's office could not bill for the "Welcome to Medicare exam".

In my reply I stated that I had had this doctor for about 20 years and my former employer required us to go for a wellness test each year. I was exempted for 2016 as I was in excellent health. In my reply, I stated that this is what my doctor did at the exam:

1. Reviewed my medical history

2. Took blood tests - included a copy of blood tests

3. I am taking medication for high cholesterol and still had high overall but good to bad was acceptable so doctor did not change medication.

4. I'm very allergic to dust mites so doctor changed medication.

5. My gynecologist retired and the doctor gave me the name of a new one. I have not been to one for about 2 years so I went for an appointment.

6. The doctor gave a referral for a Mammogram. I had not been for about two years and don't really believe in them and I am not a high risk factor. Still I went and the results confirmed this.

7. I haven't been for a bone density test for a while so the doctor referred me. The results showed my bones aren't so strong so I was sent to the hospital for an bi-annual injection. I was asked by the nurse practitioner if I was on a walker. I laughed and told her that I hauled 40 bags of soil a few days ago. Yesterday it was only 26 bags. Again I'm not a great believer in these injections. Osteoporosis is a risk factor for me as my mother fell and broke her hip at 92. Unlike me she had high blood pressure and some heart issues. She only survived the operation for 4 days.

Its ironic that I don't really believe in these preventive tests but I'm the one who is rejected. The wellness test was my first and only visit to the doctor in nearly two years.

We'll see where the chips fall.

Incidentally when the doctor took my blood pressure, he muttered "Fantastic". Maybe it isn't now. :D

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Thu Jun 22, 2017 2:40 pm

Lynette wrote:7. I haven't been for a bone density test for a while so the doctor referred me. The results showed my bones aren't so strong so I was sent to the hospital for an bi-annual injection. I was asked by the nurse practitioner if I was on a walker. I laughed and told her that I hauled 40 bags of soil a few days ago. Yesterday it was only 26 bags. Again I'm not a great believer in these injections. Osteoporosis is a risk factor for me as my mother fell and broke her hip at 92. Unlike me she had high blood pressure and some heart issues. She only survived the operation for 4 days.


A good doctor will also obtain dental clearance before starting you on this medication which is most likely Reclast, Prolia, or similar medications. I remove portions of someone's jaw bones about once a month due to this medication being given with no regard to their dental health.

kaneohe
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Re: Please explain how Medicare Billing works?

Postby kaneohe » Thu Jun 22, 2017 3:02 pm

Lynette wrote:
BL wrote:Just want to add that there is probably not only a co-payment but a deductible amount for each year with Medicare and, I suspect, your supplement policy. That would also show up with the first visit of the year.
Part B deductible $183 per year


I have Medigap F - do I still have a deductible?


You have a deductible but it is covered by Medigap F.https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 3:26 pm

It was Prolia. I think that there is no good solution. A few years ago I was on Fosamax but discontinued this due to time I had been on it and negative publicity associated with it. Maybe I should stop these wellness tests. My former employer essentially forced us to go on them as we had to pay a higher premium if we did not complete them by the end of March.

dennisbyron
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Re: Please explain how Medicare Billing works?

Postby dennisbyron » Thu Jun 22, 2017 5:20 pm

"Maybe it is not a billing code issue."


It sure sounds like a billing code issue because what you described is a textbook Welcome to Medicare Visit or Annual Wellness Visit (see page 60 of the 2017 "Medicare and You" book). The only thing that confuses me are the words "physical exam" in your denial letter. Those words may be causing the problem. Medicare does not pay for a classic annual physical exam, either in the first year or in any subsequent years. It only pays for the "talking to the doctor" that you described. That's why Medicare calls it a "visit."

Ask the doctor's office if you are his or her only Medicare patient. This is cookie cutter stuff for most doctors who take Medicare patients (although they do not like the "visits" because they are not exams; the nurses call them "non nakeds").

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Thu Jun 22, 2017 5:58 pm

I live in South East Michigan and when I visit the doctor's office it is full of elderly patients. My doctor assured me that he took Medicare and the office told me I would not be billed. I think that the office dropped the ball somehow or other which is why they have not returned my calls. I think that they may not have included enough details ... I'll give it a few days .... I also need a break from this ...

Thanks for all of the replies and suggestions.

mouses
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Re: Please explain how Medicare Billing works?

Postby mouses » Thu Jun 22, 2017 6:01 pm

toofache32 wrote:
Lynette wrote:7. I haven't been for a bone density test for a while so the doctor referred me. The results showed my bones aren't so strong so I was sent to the hospital for an bi-annual injection. I was asked by the nurse practitioner if I was on a walker. I laughed and told her that I hauled 40 bags of soil a few days ago. Yesterday it was only 26 bags. Again I'm not a great believer in these injections. Osteoporosis is a risk factor for me as my mother fell and broke her hip at 92. Unlike me she had high blood pressure and some heart issues. She only survived the operation for 4 days.


A good doctor will also obtain dental clearance before starting you on this medication which is most likely Reclast, Prolia, or similar medications. I remove portions of someone's jaw bones about once a month due to this medication being given with no regard to their dental health.


Yeah, jaw death. I was shocked when I read about this, and it had never been mentioned to me as a risk factor. Fortunately I had stopped the med for other reasons.

kaneohe
Posts: 4191
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Re: Please explain how Medicare Billing works?

Postby kaneohe » Thu Jun 22, 2017 6:21 pm

from the Medicare and You 2017 Publication:

“Welcome to Medicare” preventive visit
During the first 12 months that you have Part B, you can get
a “Welcome to Medicare” preventive visit. This visit includes
a review of your medical and social history related to your
health, and education and counseling about preventive services,
including certain screenings, shots, and referrals for other care,
if needed. When you make your appointment, let your doctor’s
office know that you’d like to schedule your “Welcome to
Medicare” preventive visit. You pay nothing for the “Welcome to
Medicare” preventive visit if the doctor or other qualified health
care provider accepts assignment.
If your doctor or other health care provider performs additional
tests or services during the same visit that aren’t covered under
this preventive benefit, you may have to pay coinsurance, and the
Part B deductible may apply.


****************************************************************************************
Seems like you may have have had other services besides the textbook
"Welcome " visit. Even so, it shouldn't matter to you as long as they were
covered services not performed too frequently. The "Welcome" visit is free to
you but w/ Medigap F & Medicare, these covered services (deductible & all)
should be covered by some combination of the two so that they would also
be free to you.

I'm assuming you didn't have any of these non-covered services done:

What’s NOT covered by Part A and Part B?
Medicare doesn’t cover everything. If you need certain services that
aren’t covered under Medicare Part A or Part B, you’ll have to pay
for them yourself unless:
■ You have other coverage (including Medicaid) to cover the costs.
■ You’re in a Medicare health plan that covers these services.
Even if Medicare covers a service or item, you generally have to pay
deductibles, coinsurance, and/or copayments.
Some of the items and services that Medicare doesn’t cover include:
✘ Most dental care.
✘ Eye examinations related to prescribing glasses.
✘ Dentures.
✘ Cosmetic surgery.
✘ Acupuncture.
✘ Hearing aids and exams for fitting them.
✘ Long-term care. See next page for more information about
paying for long-term care.
✘ Concierge care (also called concierge medicine, retainer-based
medicine, boutique medicine, platinum practice, or direct care)


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