Please explain how Medicare Billing works?

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roflwaffle
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Re: Please explain how Medicare Billing works?

Postby roflwaffle » Thu Jun 22, 2017 8:17 pm

toofache32 wrote:I hope for your sake this is not that UHC AARP "Secure Horizons" plan. Denial is the name of the game.

Oh jeez, there isn't a single claim on my grandma's account that wasn't denied. On the plus side, they apparently work everything out because we've never had a provider bill for something Medicare didn't cover. :?

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Thu Jun 22, 2017 9:19 pm

mouses wrote:
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.


It stays in your body 11 years.

Grogs
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Re: Please explain how Medicare Billing works?

Postby Grogs » Thu Jun 22, 2017 9:30 pm

toofache32 wrote:
Lynette wrote:
nisiprius wrote:Pssst. By the way. Apple, penny, table. Also, DEFPOTEC.



????


I'm just as confused.


The apple, penny, table thing is the short term memory test. They tell you three words, then a short time later ask you what they were. I'm well short of Medicare age, but I used to be enrolled in a program at work that required an annual psych exam and that was part of it. Seems like they all tend to use the same words. I'm guessing DEFPOTEC is a line on the eye chart.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Fri Jun 23, 2017 5:49 am

kaneohe wrote: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)


No, I did not have any of these services. As I mentioned above, I have not been to this internist for nearly two years as I was exempted from the annual wellness test in 2016 by my employer. My doctor is usually careful in letting me know how often I should go for these services - e.g. bone density every x years, etc. etc.

The doctor's office told me that Medicare would cover this examination. The billing clerk has not returned my calls. Either she is on vacation, too busy or made a mistake and too embarrassed to admit this. I'll give them a few days and then go and visit the office if they do not contact me. This is the advantage of being retired :D. I like this doctor and have been a patient for nearly 20 years. I have not had any problems with them in the past.

This has been quite an experience. With IRMAA premiums for Parts A & D, and Medigap F, I am paying about $500 a month. While employed, I paid $160 a month in premiums. Many questions on this board are about taking early retirement and living in another country until they qualify for Medicare. It seems I may have to go and live overseas to escape Medicare!

kaneohe
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Re: Please explain how Medicare Billing works?

Postby kaneohe » Fri Jun 23, 2017 8:27 am

Lynette wrote:..........................................

This has been quite an experience. With IRMAA premiums for Parts A & D, and Medigap F, I am paying about $500 a month. While employed, I paid $160 a month in premiums. Many questions on this board are about taking early retirement and living in another country until they qualify for Medicare. It seems I may have to go and live overseas to escape Medicare!


Lynette.........I sense that there may also be a mismatch in time constants here. You seem to be a go-getter-get-things-done-now type with a 1 millisecond time constant while the doctor's office/Medicare are more like manana (if ever). Perhaps if you can determine if it would be easier for
them to be like you or for you to be like them, you might not have to move overseas :happy Remember....this too shall pass.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Fri Jun 23, 2017 12:40 pm

kaneohe wrote:
Lynette wrote:..........................................

This has been quite an experience. With IRMAA premiums for Parts A & D, and Medigap F, I am paying about $500 a month. While employed, I paid $160 a month in premiums. Many questions on this board are about taking early retirement and living in another country until they qualify for Medicare. It seems I may have to go and live overseas to escape Medicare!


Lynette.........I sense that there may also be a mismatch in time constants here. You seem to be a go-getter-get-things-done-now type with a 1 millisecond time constant while the doctor's office/Medicare are more like manana (if ever). Perhaps if you can determine if it would be easier for
them to be like you or for you to be like them, you might not have to move overseas :happy Remember....this too shall pass.


:D :D Thanks for the reminder. You analyzed me correctly. I having my house and garden remodeled at the moment and one has to learn patience as contractors are busy, don't return calls, don't show up for appointments etc. I'm pleased that they have work after the tough time they had in 2008-9 but its frustration for the homeowner. To my one handyman's amazement, I stripped the paint off of 15 cabinet doors in my garage as he was not available. He tells all of his other clients about this old lady who did it herself as she could not wait. :D

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FrugalInvestor
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Re: Please explain how Medicare Billing works?

Postby FrugalInvestor » Fri Jun 23, 2017 1:23 pm

Lynette,

I understand your frustration in general and with the Medicare billing in particular.

I recently went on Medicare and was confused by what I was reading on the Medicare site regarding my 'welcome to Medicare' visit, annual visits (or whatever they're called), preventative care, etc. I called my doctors office and was told my (first) visit would be covered but I knew it was more than the 'welcome to Medicare' would cover. When I pressed I was told that the office just had a "big meeting" on the subject because everyone was confused about it and after checking with the meeting leader they said "yes," it will be covered.

I then called Medciare and they told me what 'welcome to Medicare' included and said that that was all I was due for the first year which made no sense to me but I asked about it at least three different ways and got the same answer. So I called my doctor's office back and told them what Medicare said. The person at the desk then told me I'd need to "talk to my insurance company." I pushed back and reminded her about the meeting I was told about and asked if she knew about it. It turned out she hadn't attended it (yet). So she then checked with the billing manager and came back and said, "it'll be covered." When I pressed more about the "welcome to Medicare" and other terminology she said something to the effect that "it's all in how it worded, but it'll be covered." I took that to mean that it needs to be coded correctly and we know how to do that.

As it turns out, it was covered and what was not will be picked up by my supplement plan. But it shouldn't be this complicated, especially for the patient.

If your proceedures aren't covered I'd suggest talk directly to the billing supervisor to try and get it worked out. They have 'coding clerks' who often may not code procedures correctly and I also think that there can be some leeway in what code(s) are applied. If it hasn't been worked out this may help in doing so. It's also important to learn to understand Medicare's billing statements as well as your supplement plan's. This is assuming you are on traditional Medicare and not an Advantage plan. Again, all very complicated. I think it will get easier and less frustrating as we become more experienced with the program.
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 » Fri Jun 23, 2017 3:57 pm

Thank you for encouraging me to get to know Medicare billing. I am on AARP Medigap F - cost about $200 a month. The letter of denial stated that the maximum I could be billed was $295. I've written a lengthy letter and filled in the other paperwork. My doctor is going on past history - e.g. one is entitled to a bone density every x years, colonoscopy every x years. I don't know if these conventions also apply to Medicare.

You are fortunate to have a human at your office to whom you can speak. The billing department at my doctor's office goes to voice mail and they don't reply.

Medicare in general has been a nightmare for me. As I worked till 73, my employer had to fill in a form stating that I had had coverage. The HR department filled in the information incorrectly and it took about four calls to Medicare and two visits to the SS office to get my Medicare B card. I guess I need to start this fun stuff of getting to know Medicare billing codes!

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FrugalInvestor
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Re: Please explain how Medicare Billing works?

Postby FrugalInvestor » Fri Jun 23, 2017 4:15 pm

Lynette wrote:Thank you for encouraging me to get to know Medicare billing. I am on AARP Medigap F - cost about $200 a month. The letter of denial stated that the maximum I could be billed was $295. I've written a lengthy letter and filled in the other paperwork. My doctor is going on past history - e.g. one is entitled to a bone density every x years, colonoscopy every x years. I don't know if these conventions also apply to Medicare.

You are fortunate to have a human at your office to whom you can speak. The billing department at my doctor's office goes to voice mail and they don't reply.

Medicare in general has been a nightmare for me. As I worked till 73, my employer had to fill in a form stating that I had had coverage. The HR department filled in the information incorrectly and it took about four calls to Medicare and two visits to the SS office to get my Medicare B card. I guess I need to start this fun stuff of getting to know Medicare billing codes!


I hate to say it but you may want to look for another doctor whose office can help you navigate Medicare. This is not just a Medicare issue. I've had similar problems prior to going on Medicare. In those cases I had to call the doctor's office, speak with the billing department and get the charges re-submitted (I assume with different billing codes) and then the denials went away. Many new regulations have been placed on doctors in recent years and most of the doctors don't like dealing with all this administrative stuff. They want to practice medicine! So if the doctor doesn't have a good administrative staff these problems become more common.

You shouldn't and probably wouldn't want to learn the medial coding system. I certainly don't. What I think you do need to do is learn to navigate the system, especially the billing side. If your doctor's office won't allow you to do that and doesn't know how to deal with Medicare and its nuances then you have a problem. I don't think you'd need to move to a foreign country to fix it but you may need to move to another doctor's office.

Medicare F is the most comprehensive policy currently available and most people I talk to who have it never seen a bill - and some have very frequent medical care.
IGNORE the noise! | Our life is frittered away by detail... simplify, simplify. - Henry David Thoreau

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FrugalInvestor
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Re: Please explain how Medicare Billing works?

Postby FrugalInvestor » Fri Jun 23, 2017 10:49 pm

Very relevant information on another discussion board (early retirement) here.....
http://www.early-retirement.org/forums/ ... 87285.html

Post from that thread...

I just started on regular Medicare last August and am learning some facts about the cost myself, so this is a timely thread.

I saw my PCP for a routine visit in May. Checking the Medicare site, I saw that the visit was denied payment from Medicare because it was coded as a "periodic preventive exam" 99397. When I checked out at the front desk I was told it would be billed as a "physical".

Doing some research I found out that this code 99397 is never covered by Medicare. There is one annual "Wellness" visit that is covered which is code G0438 or G0439, but this would not have applied to me because I had Medicare less than 12 months, and had already had the "Welcome to Medicare" visit coded G0402 within those 12 months.

I have already met my Medicare Part B deductible for the year. I have a high deductible plan F which didn't pay for two reasons: It was denied by Medicare and I have not reached the deductible. So.....I am surprised to realize I will be paying the full $225.00 billed by my provider. I assume providers use this code so they will be paid the full billing amount and not have to accept a discounted amount from Medicare.

I'm being treated by this PCP for hypertension and high cholesterol, so it's not as if there is nothing to claim treatment for. I will have some discussion with my PCP at the next visit regarding her plans for coding future visits, but this is a good learning for me related to Medicare costs.
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 » Sat Jun 24, 2017 5:44 am

Thank you. I think there are two issues:

1. I was coded for (G0439) instead of welcome to medicare exam (G0402). These problems arise as I retired at 73 instead of 65.

2. The Welcome to Medicare is supposed to be for screenings and possibly shots. There did not appear to be any tests done on my Welcome to Medicare. I have been with this doctor for many years and gives me screenings such as EKG occasionally. He felt it was not necessary to do it this time.

While I was employed there was never any problem with billing and we were virtually forced to go on these annual wellness tests or else we would be on a higher rate. If we did not go we constantly got reminders from the Health care provider that the deadline was approaching.

I suppose that the doctor's office could discuss billing with me. I have not had a reply in the past few days so I'm a little fedup with the office. I have copied them on all of the documentation. I will see what happens and if required go and visit them.

MPAndy222
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Re: Please explain how Medicare Billing works?

Postby MPAndy222 » Sat Jun 24, 2017 5:55 am

Lynette wrote:Thank you. I think there are two issues:

1. I was coded for (G0439) instead of welcome to medicare exam (G0402). These problems arise as I retired at 73 instead of 65.

2. The Welcome to Medicare is supposed to be for screenings and possibly shots. There did not appear to be any tests done on my Welcome to Medicare. I have been with this doctor for many years and gives me screenings such as EKG occasionally. He felt it was not necessary to do it this time.

While I was employed there was never any problem with billing and we were virtually forced to go on these annual wellness tests or else we would be on a higher rate. If we did not go we constantly got reminders from the Health care provider that the deadline was approaching.

I suppose that the doctor's office could discuss billing with me. I have not had a reply in the past few days so I'm a little fedup with the office. I have copied them on all of the documentation. I will see what happens and if required go and visit them.


The G0439 coding is what I expected happened. Again the welcome to Medicare exam requires eye exam, hearing test, EKG, and questions about mood, memory, balance, safety, etc. They should have asked about cancer screening (for your age breast cancer screening, colon cancer screening, and osteoporosis screening) and immunization status (both pneumonia shots). If the physician did not do all of the above and if it was not documented correctly then Medicare may not pay. They needed to do an EKG regardless if the physician felt like you didn't need it. I would continue to work with your physician's office to get it recoded correctly

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Sat Jun 24, 2017 6:34 am

Thanks. As I mentioned I am a long-time patient and my doctor knows my history. He did check my heart beat but did not do an EKG this time. Last time he took an EKG, my results had improved as I had been swimming.

Thank you.

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Mon Jul 03, 2017 2:22 pm

MPAndy222 wrote:
Lynette wrote:Thank you. I think there are two issues:

1. I was coded for (G0439) instead of welcome to medicare exam (G0402). These problems arise as I retired at 73 instead of 65.

2. The Welcome to Medicare is supposed to be for screenings and possibly shots. There did not appear to be any tests done on my Welcome to Medicare. I have been with this doctor for many years and gives me screenings such as EKG occasionally. He felt it was not necessary to do it this time.

While I was employed there was never any problem with billing and we were virtually forced to go on these annual wellness tests or else we would be on a higher rate. If we did not go we constantly got reminders from the Health care provider that the deadline was approaching.

I suppose that the doctor's office could discuss billing with me. I have not had a reply in the past few days so I'm a little fedup with the office. I have copied them on all of the documentation. I will see what happens and if required go and visit them.


The G0439 coding is what I expected happened. Again the welcome to Medicare exam requires eye exam, hearing test, EKG, and questions about mood, memory, balance, safety, etc. They should have asked about cancer screening (for your age breast cancer screening, colon cancer screening, and osteoporosis screening) and immunization status (both pneumonia shots). If the physician did not do all of the above and if it was not documented correctly then Medicare may not pay. They needed to do an EKG regardless if the physician felt like you didn't need it. I would continue to work with your physician's office to get it recoded correctly


Thanks you Andy. Today I got an EOB from United Healthcare which stated that they did not pay anything as Medicare turned down the claim. So I decided, time for action. Leaving a voicemail with the doctor's office did not result in a reply. So I used the number for new appointments and mentioned that I had not had a reply. I then spoke to the billing lady who said that the medicare had paid. As mentioned by Andy the billing code was wrong. So thanks to Andy and everyone else for assistance.

Lesson learned: NEVER WORK BEYOND 65 IF YOU WANT TO AVOID HASSLES WITH MEDICARE!

Oh well - guess I have been fortunate to have a job and good health until 73. As I have pensions and SS taken at 70, I felt I could afford to go overseas 4 or 5 times a year for the past 20 years. I have been fortunate. Bureaucratic hassles go away.

Thanks all,

Lynette

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Mon Jul 03, 2017 7:42 pm

The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.

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dm200
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Re: Please explain how Medicare Billing works?

Postby dm200 » Tue Jul 04, 2017 9:50 am

toofache32 wrote:The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.


Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Tue Jul 04, 2017 3:43 pm

dm200 wrote:
toofache32 wrote:The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.


Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.


Are they private docs or part of an institutional practice. In other words, are they eligible to charge facility fees? This is the main reason Medicare and Medicaid patients will soon be required to seek in network care in a clinic/institutional type setting instead of a private practice.

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FrugalInvestor
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Re: Please explain how Medicare Billing works?

Postby FrugalInvestor » Tue Jul 04, 2017 3:58 pm

toofache32 wrote:
dm200 wrote:
toofache32 wrote:The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.


Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.


Are they private docs or part of an institutional practice. In other words, are they eligible to charge facility fees? This is the main reason Medicare and Medicaid patients will soon be required to seek in network care in a clinic/institutional type setting instead of a private practice.


Can you explain this further toofache32?
IGNORE the noise! | Our life is frittered away by detail... simplify, simplify. - Henry David Thoreau

Miriam2
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Re: Please explain how Medicare Billing works?

Postby Miriam2 » Tue Jul 04, 2017 4:04 pm

Lynette wrote: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.

Lynette, I remember distinctly that in another thread - where you were again climbing tall trees to chop them down with your chainsaw - that your fellow Bogleheads told you that you cannot do this anymore :shock: :annoyed :happy we can't have a chainsaw cutting short :mrgreen: our Lynette's best laid retirement plans :beer

Lynette
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Re: Please explain how Medicare Billing works?

Postby Lynette » Tue Jul 04, 2017 5:03 pm

Miriam2 wrote:
Lynette wrote: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.

Lynette, I remember distinctly that in another thread - where you were again climbing tall trees to chop them down with your chainsaw - that your fellow Bogleheads told you that you cannot do this anymore :shock: :annoyed :happy we can't have a chainsaw cutting short :mrgreen: our Lynette's best laid retirement plans :beer


:D Miriam, trees are all gone. I used my chainsaw to cut some roots - not advisable as roots are like rocks. I did not feel like getting a new chain so gave it to my handyman. Its amazing what you don't notice around your house while working - leave early in the morning and get home late at night. I had some trees that formed were along the fence. I did not notice how large they had grown - right into my neighbor's yard and weakening the fence. My neighbor's tree-cutting service gave me a very reasonable quote so I had the trees cut down and the stumps ground. I bought replacement shrubs and planted them - only 26 bags mulch. :D End of gardening for this year! Tomorrow I start Spanish at a local community college.

toofache32
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Re: Please explain how Medicare Billing works?

Postby toofache32 » Tue Jul 04, 2017 5:27 pm

FrugalInvestor wrote:
toofache32 wrote:
dm200 wrote:
toofache32 wrote:The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.


Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.


Are they private docs or part of an institutional practice. In other words, are they eligible to charge facility fees? This is the main reason Medicare and Medicaid patients will soon be required to seek in network care in a clinic/institutional type setting instead of a private practice.


Can you explain this further toofache32?


Institutional settings such as hospitals and "facilities" are allowed to charge a "facility fee" to insurance companies in addition to the regular office visit. Private docs are not allowed to bill facility fees and can only charge the smaller office visit code. Combine a lower amount payable to a private doc with ever-increasing costs to collect, and it's just not worth it at some point to stay in network. The lowest payers (government programs) are the first to get dropped and the "facilities" are what's left. I suppose the facility fees are profitable because hospitals chase after them. There are many private offices that get bought by a facility and are then somehow eligible to charge facility fees supposedly, but those docs are now employees.

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FrugalInvestor
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Re: Please explain how Medicare Billing works?

Postby FrugalInvestor » Tue Jul 04, 2017 7:01 pm

toofache32 wrote:
FrugalInvestor wrote:
toofache32 wrote:
dm200 wrote:
toofache32 wrote:The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.


Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.
dri

Are they private docs or part of an institutional practice. In other words, are they eligible to charge facility fees? This is the main reason Medicare and Medicaid patients will soon be required to seek in network care in a clinic/institutional type setting instead of a private practice.


Can you explain this further toofache32?


Institutional settings such as hospitals and "facilities" are allowed to charge a "facility fee" to insurance companies in addition to the regular office visit. Private docs are not allowed to bill facility fees and can only charge the smaller office visit code. Combine a lower amount payable to a private doc with ever-increasing costs to collect, and it's just not worth it at some point to stay in network. The lowest payers (government programs) are the first to get dropped and the "facilities" are what's left. I suppose the facility fees are profitable because hospitals chase after them. There are many private offices that get bought by a facility and are then somehow eligible to charge facility fees supposedly, but those docs are now employees.


I've noticed this from a patient's perspective. It seems that the 'facilities' are favored. Why is this? Are they viewed as more able/likely to drive efficiencies in the system?
IGNORE the noise! | Our life is frittered away by detail... simplify, simplify. - Henry David Thoreau

pshonore
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Re: Please explain how Medicare Billing works?

Postby pshonore » Tue Jul 04, 2017 7:18 pm

toofache32 wrote:
FrugalInvestor wrote:
toofache32 wrote:
dm200 wrote:
toofache32 wrote:The sad part is that when Medicare and insurance companies make getting paid so burdensome, frustrating, and expensive....many private docs just drop the plan. That's what I did in my office.


Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.


Are they private docs or part of an institutional practice. In other words, are they eligible to charge facility fees? This is the main reason Medicare and Medicaid patients will soon be required to seek in network care in a clinic/institutional type setting instead of a private practice.


Can you explain this further toofache32?


Institutional settings such as hospitals and "facilities" are allowed to charge a "facility fee" to insurance companies in addition to the regular office visit. Private docs are not allowed to bill facility fees and can only charge the smaller office visit code. Combine a lower amount payable to a private doc with ever-increasing costs to collect, and it's just not worth it at some point to stay in network. The lowest payers (government programs) are the first to get dropped and the "facilities" are what's left. I suppose the facility fees are profitable because hospitals chase after them. There are many private offices that get bought by a facility and are then somehow eligible to charge facility fees supposedly, but those docs are now employees.
And since the office real estate is now owned by the hospital, no property taxes are paid. Almost sounds like a shell game. CT is considering allowing cities and towns to assess property taxes on hospital property which has historically been tax exempt.

toofache32
Posts: 899
Joined: Sun Mar 04, 2012 6:30 pm

Re: Please explain how Medicare Billing works?

Postby toofache32 » Tue Jul 04, 2017 7:37 pm

FrugalInvestor wrote:
toofache32 wrote:
FrugalInvestor wrote:
toofache32 wrote:
dm200 wrote:
Are there some primary care Physicians who, legitimately, are able to have profitable Medicare practices? I notice that, in this area, the Medicare Advantage and Medicare Cost providers do a lot of promotion and advertising - so they must have a positive financial bottom line.
dri

Are they private docs or part of an institutional practice. In other words, are they eligible to charge facility fees? This is the main reason Medicare and Medicaid patients will soon be required to seek in network care in a clinic/institutional type setting instead of a private practice.


Can you explain this further toofache32?


Institutional settings such as hospitals and "facilities" are allowed to charge a "facility fee" to insurance companies in addition to the regular office visit. Private docs are not allowed to bill facility fees and can only charge the smaller office visit code. Combine a lower amount payable to a private doc with ever-increasing costs to collect, and it's just not worth it at some point to stay in network. The lowest payers (government programs) are the first to get dropped and the "facilities" are what's left. I suppose the facility fees are profitable because hospitals chase after them. There are many private offices that get bought by a facility and are then somehow eligible to charge facility fees supposedly, but those docs are now employees.


I've noticed this from a patient's perspective. It seems that the 'facilities' are favored. Why is this? Are they viewed as more able/likely to drive efficiencies in the system?


I have no idea but it definitely increases costs for the insurance because they are paying more (sometimes 2-3x more) for the same service. While a facility uses these extra fees to pay for staffing, equipment, etc...in my private office I have to use only the office fees to pay all my employees, etc. Which is one big reason I am no longer in-network with medical insurance.

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sat Jul 15, 2017 3:04 pm

So the saga continues. I have my own Appeals Adjuster from the Redetermination Office. I received a letter that I was to submit any further documentation in 14 days. My doctor's office told me that they resubmitted the claim for G0402 instead of welcome to medicare exam G0439. However the denial was for G0439 so I am continuing to with the appeal as I have no evidence that the claim was resubmitted. I got a letter from AARP United Health Care and called them. They told me that if the claim had been resubmitted, there was nothing further I had to do except that I had now received this letter.

No more doctor visits this year!!!! Maybe if I die, they will take my corpse to determine cause of death. I'm paying $500 a month for this hassle!!!

toofache32
Posts: 899
Joined: Sun Mar 04, 2012 6:30 pm

Re: Please explain how Medicare Billing works?

Postby toofache32 » Sat Jul 15, 2017 8:31 pm

toofache32 wrote:I hope for your sake this is not that UHC AARP "Secure Horizons" plan. Denial is the name of the game.


Is this the Secure Horizons plan?

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sat Jul 15, 2017 8:37 pm

No, it is Medigap F. I have to pay IRMAA Medicare Premiums for Medicare B and D of about $300 a month. I have AARP United Health Care Medigap F for about $200 a month. Then I have Humana Drug coverage but this is really cheap - about $17 a month. My copay for 2 prescriptions are also really cheap. The lady on the phone said that they did not cover it unless Medicare did. I did not bother to go into further details. I haven't seen a bill yet so I'll see what the appeal decides. I guess I could call but they write me letters so I will write letters back and copy everyone.

toofache32
Posts: 899
Joined: Sun Mar 04, 2012 6:30 pm

Re: Please explain how Medicare Billing works?

Postby toofache32 » Sat Jul 15, 2017 8:52 pm

You get what they pay for. This is Medicare after all.

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sat Jul 15, 2017 9:09 pm

The Doctor's office told me that the visit would be fully covered. Initially they did not return my calls but only when I the receptionist was I put through to the billing clerk. She said she had resubmitted the claim with the other billing code. Part of the letter from Medicare for refusal was that not enough screening was performed. It is not my fault if the doctor determines not to give me an EKG because the last one done was excellent and that it had improved. I am swimming. He did send me for a bone density test which was necessary. We'll see how this unfolds.

Life was so simple when I was employed. I was mandated to go for Wellness Tests. My doctor gave me referrals for other exams. Now I have this awful Medicare with whom to deal.

Miriam2
Posts: 1600
Joined: Fri Nov 14, 2014 11:51 am

Re: Please explain how Medicare Billing works?

Postby Miriam2 » Sat Jul 15, 2017 9:28 pm

Lynette wrote:So the saga continues . . . No more doctor visits this year!!!! Maybe if I die, they will take my corpse to determine cause of death.

No Lynette, sorry, but you'll have to pay for your own autopsy - Medicare stopped paying directly for autopsies in 1986.

Post-death body examination to determine cause of death
What's Covered
Neither Medicare Part A, Medicare Part B, nor a Medicare Part C Medicare Advantage plan covers any post-death examination or procedure, including autopsy.

What Medicare Pays
Neither Medicare nor a Medicare Part C plan pays anything for an autopsy.

https://www.caring.com/medicare_informa ... of-autopsy

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sat Jul 15, 2017 9:35 pm

Miriam2 wrote:
Lynette wrote:So the saga continues . . . No more doctor visits this year!!!! Maybe if I die, they will take my corpse to determine cause of death.

No Lynette, sorry, but you'll have to pay for your own autopsy - Medicare stopped paying directly for autopsies in 1986.

Post-death body examination to determine cause of death
What's Covered
Neither Medicare Part A, Medicare Part B, nor a Medicare Part C Medicare Advantage plan covers any post-death examination or procedure, including autopsy.

What Medicare Pays
Neither Medicare nor a Medicare Part C plan pays anything for an autopsy.

https://www.caring.com/medicare_informa ... of-autopsy
:D :D

Seriously? If no one hears from me for a few days and then they find me dead, will my estate have to pay for the autopsy to determine cause of death. What if my relatives don't want an autopsy but the state suspects foul play and they decide an autopsy is necessary.

MPAndy222
Posts: 36
Joined: Thu Mar 31, 2016 6:26 pm

Re: Please explain how Medicare Billing works?

Postby MPAndy222 » Sat Jul 15, 2017 9:48 pm

Lynette wrote:The Doctor's office told me that the visit would be fully covered. Initially they did not return my calls but only when I the receptionist was I put through to the billing clerk. She said she had resubmitted the claim with the other billing code. Part of the letter from Medicare for refusal was that not enough screening was performed. It is not my fault if the doctor determines not to give me an EKG because the last one done was excellent and that it had improved. I am swimming. He did send me for a bone density test which was necessary. We'll see how this unfolds.

Life was so simple when I was employed. I was mandated to go for Wellness Tests. My doctor gave me referrals for other exams. Now I have this awful Medicare with whom to deal.


Again to charge for the Welcome to Medicare exam the doctor needs to fulfill the criteria (depression screening, safety, hearing, vision, memory, cancer screening, immunization screening, and EKG). If the doctor didn't meet the criteria for the billing given then that is fraud and you shouldn't have to pay the bill. The doctor needs to resubmit the appropriate coding (if they did everything but an EKG then the annual Medicare wellness exam would be appropriate). Keep fighting

Miriam2
Posts: 1600
Joined: Fri Nov 14, 2014 11:51 am

Re: Please explain how Medicare Billing works?

Postby Miriam2 » Sat Jul 15, 2017 9:49 pm

Lynette wrote:Seriously? If no one hears from me for a few days and then they find me dead, will my estate have to pay for the autopsy to determine cause of death. What if my relatives don't want an autopsy but the state suspects foul play and they decide an autopsy is necessary.

If the state suspects foul play, the state will pay for the autopsy.

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sat Jul 15, 2017 10:20 pm

MPAndy222 wrote:
Lynette wrote:The Doctor's office told me that the visit would be fully covered. Initially they did not return my calls but only when I the receptionist was I put through to the billing clerk. She said she had resubmitted the claim with the other billing code. Part of the letter from Medicare for refusal was that not enough screening was performed. It is not my fault if the doctor determines not to give me an EKG because the last one done was excellent and that it had improved. I am swimming. He did send me for a bone density test which was necessary. We'll see how this unfolds.

Life was so simple when I was employed. I was mandated to go for Wellness Tests. My doctor gave me referrals for other exams. Now I have this awful Medicare with whom to deal.


Again to charge for the Welcome to Medicare exam the doctor needs to fulfill the criteria (depression screening, safety, hearing, vision, memory, cancer screening, immunization screening, and EKG). If the doctor didn't meet the criteria for the billing given then that is fraud and you shouldn't have to pay the bill. The doctor needs to resubmit the appropriate coding (if they did everything but an EKG then the annual Medicare wellness exam would be appropriate). Keep fighting


Thanks Andy. The doctors has known me for 15 - 20 years and knows my history. It would be strange for him to suddenly make a big deal of a hearing test when it obvious that I am not having problems. The same applies to vision. He sends me for tests when he feels the timing is appropriate. This time he gave me a referral for a bone density and mammogram. The latter two especially bone density is necessary whereas depression is not. The doctor did not have the time to listen to my stories of gardening.

MPAndy222
Posts: 36
Joined: Thu Mar 31, 2016 6:26 pm

Re: Please explain how Medicare Billing works?

Postby MPAndy222 » Sat Jul 15, 2017 10:43 pm

Lynette wrote:
MPAndy222 wrote:
Lynette wrote:The Doctor's office told me that the visit would be fully covered. Initially they did not return my calls but only when I the receptionist was I put through to the billing clerk. She said she had resubmitted the claim with the other billing code. Part of the letter from Medicare for refusal was that not enough screening was performed. It is not my fault if the doctor determines not to give me an EKG because the last one done was excellent and that it had improved. I am swimming. He did send me for a bone density test which was necessary. We'll see how this unfolds.

Life was so simple when I was employed. I was mandated to go for Wellness Tests. My doctor gave me referrals for other exams. Now I have this awful Medicare with whom to deal.


Again to charge for the Welcome to Medicare exam the doctor needs to fulfill the criteria (depression screening, safety, hearing, vision, memory, cancer screening, immunization screening, and EKG). If the doctor didn't meet the criteria for the billing given then that is fraud and you shouldn't have to pay the bill. The doctor needs to resubmit the appropriate coding (if they did everything but an EKG then the annual Medicare wellness exam would be appropriate). Keep fighting


Thanks Andy. The doctors has known me for 15 - 20 years and knows my history. It would be strange for him to suddenly make a big deal of a hearing test when it obvious that I am not having problems. The same applies to vision. He sends me for tests when he feels the timing is appropriate. This time he gave me a referral for a bone density and mammogram. The latter two especially bone density is necessary whereas depression is not. The doctor did not have the time to listen to my stories of gardening.


Unfortunately Medicare doesn't know if you are perfectly healthy. As part of the change to population management, Medicare wants certain screening criteria to be documented. The doctor needed to screen you for all of the appropriate tests (it doesn't matter how well he knows you, if the tests seem unnecessary, or if you had similar tests the day before joining Medicare). If they billed a welcome to Medicare exam they had to satisfy all of the criteria else it would be denied (which it was). This is standard acrossed the nation. Your doctor needs to learn the criteria of the welcome to Medicare exam to bill appropriately

toofache32
Posts: 899
Joined: Sun Mar 04, 2012 6:30 pm

Re: Please explain how Medicare Billing works?

Postby toofache32 » Sun Jul 16, 2017 10:03 am

It sounds like the Welcome to Medicare visit wasn't indicated.

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jul 16, 2017 11:01 am

duplicate - deleted
Last edited by Lynette on Sun Jul 16, 2017 3:53 pm, edited 1 time in total.

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jul 16, 2017 11:05 am

MPAndy222 wrote:
Lynette wrote:
MPAndy222 wrote:
Lynette wrote:The Doctor's office told me that the visit would be fully covered. Initially they did not return my calls but only when I the receptionist was I put through to the billing clerk. She said she had resubmitted the claim with the other billing code. Part of the letter from Medicare for refusal was that not enough screening was performed. It is not my fault if the doctor determines not to give me an EKG because the last one done was excellent and that it had improved. I am swimming. He did send me for a bone density test which was necessary. We'll see how this unfolds.

Life was so simple when I was employed. I was mandated to go for Wellness Tests. My doctor gave me referrals for other exams. Now I have this awful Medicare with whom to deal.


Again to charge for the Welcome to Medicare exam the doctor needs to fulfill the criteria (depression screening, safety, hearing, vision, memory, cancer screening, immunization screening, and EKG). If the doctor didn't meet the criteria for the billing given then that is fraud and you shouldn't have to pay the bill. The doctor needs to resubmit the appropriate coding (if they did everything but an EKG then the annual Medicare wellness exam would be appropriate). Keep fighting


Thanks Andy. The doctors has known me for 15 - 20 years and knows my history. It would be strange for him to suddenly make a big deal of a hearing test when it obvious that I am not having problems. The same applies to vision. He sends me for tests when he feels the timing is appropriate. This time he gave me a referral for a bone density and mammogram. The latter two especially bone density is necessary whereas depression is not. The doctor did not have the time to listen to my stories of gardening.


Unfortunately Medicare doesn't know if you are perfectly healthy. As part of the change to population management, Medicare wants certain screening criteria to be documented. The doctor needed to screen you for all of the appropriate tests (it doesn't matter how well he knows you, if the tests seem unnecessary, or if you had similar tests the day before joining Medicare). If they billed a welcome to Medicare exam they had to satisfy all of the criteria else it would be denied (which it was). This is standard acrossed the nation. Your doctor needs to learn the criteria of the welcome to Medicare exam to bill appropriately


Thank you Andy. I do not see why I should pay if my doctor's office said the visit was covered but it was denied as they did not perform all of the documented tests. I completed and mailed my appeal.

likegarden
Posts: 2257
Joined: Mon Feb 26, 2007 5:33 pm

Re: Please explain how Medicare Billing works?

Postby likegarden » Sun Jul 16, 2017 11:41 am

I am on Medicare for 12 years and never had to talk or write to Medicare. I have Medicare A&B and a supplementary HMO insurance which also provides a prescription drug plan. I do not pay directly to doctors, clinics and hospitals, except the initial co-payment, and they do not bill me directly. That's why I signed up with that insurance company, to handle all that billing confusion.

Lynette
Posts: 1266
Joined: Sun Jul 27, 2014 9:47 am

Re: Please explain how Medicare Billing works?

Postby Lynette » Sun Jul 16, 2017 1:00 pm

likegarden wrote:I am on Medicare for 12 years and never had to talk or write to Medicare. I have Medicare A&B and a supplementary HMO insurance which also provides a prescription drug plan. I do not pay directly to doctors, clinics and hospitals, except the initial co-payment, and they do not bill me directly. That's why I signed up with that insurance company, to handle all that billing confusion.


Thank you. I may reconsider my options next year as this is a nightmare experience. I signed up for Medigap F as I thought it would provide me with the best coverage even though it is more expensive than many of the local HMO's. I was also considering relocating to the Greater DC area to be closer to family and I thought it would be easier to change if I had an AARP Medigap F plan. I've decided not to relocate in the short term.

montanagirl
Posts: 766
Joined: Thu Nov 19, 2009 4:55 pm
Location: Montana

Re: Please explain how Medicare Billing works?

Postby montanagirl » Sun Jul 16, 2017 3:04 pm

Grasshopper wrote: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.


Same happened to me. I asked expressly for the Welcome visit but it was coded as an annual. Easy mistake since I always went in for an annual anyway.

U emailed Billing and it got fixed after a few months.


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