Please explain how Medicare Billing works? Update

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Lynette
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Re: Please explain how Medicare Billing works? Update

Post by Lynette » Tue Aug 22, 2017 1:00 pm

I was determined to have a written copy of acceptance/rejection by Medicare so I did not call them. I gave in and called. I was told that the first contested request was rejected but a second one approved. I'm not checking their website. I was told that Medicare approved "medically necessary" procedures but will not vouch for them in advance. It seems the acceptance or rejection depends on the billing code. I'll address this issue next year - if/when I decide to go to a doctor again - unlikely as it may affect my nearly perfect blood pressure score!

The Wizard
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Location: Reading, MA

Re: Please explain how Medicare Billing works? Update

Post by The Wizard » Tue Aug 22, 2017 1:45 pm

I also pay a little over $500 per month for Medicare B (higher IRMAA tier) plus a Medicare Advantage plan from Harvard Pilgrim Healthcare, which includes prescription drug coverage.
But in 2-1/2 years so far, I can't say I've have any problems like Lynette has.
Perhaps the problem is more with the heathcare provider not knowing how to work the Medicare system?
Attempted new signature...

Lynette
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Re: Please explain how Medicare Billing works? Update

Post by Lynette » Tue Aug 22, 2017 2:03 pm

The problem is that I retired at 73 instead of the standard 65. So the doctor's office, my HR department, SS and Medicare all get mixed up. It took me 4 months to get Medicare B card and now months to sort out the billing code for Welcome to Medicare.

The Wizard
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Re: Please explain how Medicare Billing works? Update

Post by The Wizard » Tue Aug 22, 2017 2:47 pm

I had something vaguely similar two years ago at 65.
A summer activity required a physical exam, so I made an appointment for it with my PCP.
Afterwards, I got a billing notice that it wasn't covered by Medicare.
I did some quick homework and then asked them about the welcome to Medicare exam. They said aha, resubmitted with different code and that was the end of that.
I did not have to deal with Medicare directly...
Attempted new signature...

MPAndy222
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Re: Please explain how Medicare Billing works?

Post by MPAndy222 » Tue Aug 22, 2017 10:10 pm

Lynette wrote:
Mon Aug 21, 2017 10:05 pm
MPAndy222 wrote:
Mon Aug 21, 2017 9:15 pm
Lynette wrote:
Mon Aug 21, 2017 8:24 pm
Well, I have received a letter from the Appeal Board that part of the claim is denied and there is still a dispute about some of it. Basically, it seems that my doctor followed the Wellness Test that my employer mandated for many years. But he did not check all of the boxes that were required by Medicare as he knows me and my medical history so well. The Doctor's office told me that I would not have to pay and it was covered by Medicare.

For now, I have had enough of this dispute. I haven't been billed for anything yet and I'm not going to call Medicare and get involved. If the doctor's office does bill me I'll pay but will probably consider changing doctors. If this doctor's office cannot follow Medicare procedures, I see no reason why I should have to go through all of this nonsense. I'm paying three times more for Medicare than when I was employed and now I have to go through this bureaucratic nightmare and it amazes me that some people seem to like Medicare!!!
If it's denied then you could potentially have the doctor do the missed items (EKG billed as Welcome to Medicare, vision screen, hearing screen, etc) and have the provider append the original note. Not sure if this is really worth the hassle though. I know this has been a bad experience, however your experience is definitely in the minority for those with Medicare. Most people don't have any issues with Medicare (as long as they don't fall into the donut hole). Hang in there. I wouldn't necessarily change doctors because of your bad billing experience - Medicare preventive visits are fairly new to the providers and unfortunately you are part of their learning curve.
Thanks - I know how my previous employer's plan worked. I have questions about two other exams.

1. I had Surface 1 Melanoma about 25 years ago - no recurrence. The office calls me about every 6 months to go for an exam. They find some or other mole to remove and then send it for biopsy. I go about once a year as I don't really think it is necessary. Do I need a referral from my primary care physician for this?

2. In addition I will need cataract surgery at some point in time. My primary care physician referred me for this and I go for annual check ups to a specialist? Do I need a referral for this?

Do I need to call Medicare every time I think I need to go to a doctor? Fortunately this is very infrequently. I'm planning to skip all doctors this year after this experience!
I can't comment on whether you need these visits as it would be giving medical advice. As far as the referral process goes most dermatologists and ophthalmologists will take self referrals. Some Medicare supplemental plans (mainly united healthcare) require all referrals come from the PCP. So the referral process depends on the exact insurance plan

MPAndy222
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Re: Please explain how Medicare Billing works?

Post by MPAndy222 » Tue Aug 22, 2017 10:20 pm

toofache32 wrote:
Mon Aug 21, 2017 9:53 pm
Lynette wrote:
Mon Aug 21, 2017 8:24 pm
If this doctor's office cannot follow Medicare procedures, I see no reason why I should have to go through all of this nonsense. I'm paying three times more for Medicare than when I was employed and now I have to go through this bureaucratic nightmare and it amazes me that some people seem to like Medicare!!!
I'm sorry you're having this frustration, but you are not the only one. This is the exact reason why Medicare is being slowly marginalized in private practice settings and will soon be left to institutional clinics to manage these patients. Medicare patients providers are working for incredibly severe discounts (20 cents on the dollar, and often for free) and the patients demand quality care for a discount....with the threat of leaving for another doctor, although this "voting with your feet" is not hurting private doctors one bit. Hospitals make a killing off Medicare but private doctors break even at best and often take a loss and do it for goodwill. In other words, Medicare patients have leverage in the institutional/hospital level but certainly not at the private practice level. Does anyone wonder why the Medicare doctors are decreasing instead of increasing? Does nobody wonder why Medicare private practices are no longer sustainable and are being purchased by hospital systems so they can charge additional facility fees? If it was worth it then private practice doctors would line up for it. CMS/Medicare needs to make it appealing if they expect doctors to be interested.
Otherwise this will complete our transition into a 2-tiered healthcare system. Government/Medicare will be available through institutional clinics where much of the care is delegated to less expensive nurses instead of doctors. The other tier will be private offices where doctors are still in control and will offer quicker, more efficient and more personalized care. This is already happening in my city.
I disagree that Medicare patients will be moving more towards institutional clinics. With CPC+ and the move towards population management, the reimbursement for Medicare patients has never been better for private PCPs. Medicare and the insurance companies are seeing the financial benefit of good PCPs - keeping patients healthier by preventing disease and keeping the patients out of the hospital. They are starting to share part of this savings with private PCPs. Medicare is paying for more care coordination to assist the PCPs care for their patients

toofache32
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Re: Please explain how Medicare Billing works?

Post by toofache32 » Tue Aug 22, 2017 10:48 pm

MPAndy222 wrote:
Tue Aug 22, 2017 10:20 pm
toofache32 wrote:
Mon Aug 21, 2017 9:53 pm
Lynette wrote:
Mon Aug 21, 2017 8:24 pm
If this doctor's office cannot follow Medicare procedures, I see no reason why I should have to go through all of this nonsense. I'm paying three times more for Medicare than when I was employed and now I have to go through this bureaucratic nightmare and it amazes me that some people seem to like Medicare!!!
I'm sorry you're having this frustration, but you are not the only one. This is the exact reason why Medicare is being slowly marginalized in private practice settings and will soon be left to institutional clinics to manage these patients. Medicare patients providers are working for incredibly severe discounts (20 cents on the dollar, and often for free) and the patients demand quality care for a discount....with the threat of leaving for another doctor, although this "voting with your feet" is not hurting private doctors one bit. Hospitals make a killing off Medicare but private doctors break even at best and often take a loss and do it for goodwill. In other words, Medicare patients have leverage in the institutional/hospital level but certainly not at the private practice level. Does anyone wonder why the Medicare doctors are decreasing instead of increasing? Does nobody wonder why Medicare private practices are no longer sustainable and are being purchased by hospital systems so they can charge additional facility fees? If it was worth it then private practice doctors would line up for it. CMS/Medicare needs to make it appealing if they expect doctors to be interested.
Otherwise this will complete our transition into a 2-tiered healthcare system. Government/Medicare will be available through institutional clinics where much of the care is delegated to less expensive nurses instead of doctors. The other tier will be private offices where doctors are still in control and will offer quicker, more efficient and more personalized care. This is already happening in my city.
I disagree that Medicare patients will be moving more towards institutional clinics. With CPC+ and the move towards population management, the reimbursement for Medicare patients has never been better for private PCPs. Medicare and the insurance companies are seeing the financial benefit of good PCPs - keeping patients healthier by preventing disease and keeping the patients out of the hospital. They are starting to share part of this savings with private PCPs. Medicare is paying for more care coordination to assist the PCPs care for their patients
I don't know much about CPC but programs have been tried in the past which similarly require complex data reporting. The increased income is minimal and is generally offset by the increased expense of creating adequate infrastructure in the practice (IT and additional staffing) to navigate the ever-changing insurance requirements of data reporting and to track the reportable measures. This is exactly why it's too burdensome for a small independent private office which leaves this only for corporate/institutional settings to employ since they are eligible to bill for facility fees which a private office is not. Every time Medicare adds new reporting requirements for participation in their program, the cost to offer care to Medicare patients goes up. I looked at one of these value-based programs in my practice back when I was in the insurance world. It would cost me $70,000 just to purchase software allowing the 3rd party to audit my charts and make sure I checked the right boxes, with the threat of withholding payment of what are already rock-bottom fees. No thank you.

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dm200
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Re: Please explain how Medicare Billing works? Update

Post by dm200 » Wed Aug 23, 2017 8:37 am

I disagree that Medicare patients will be moving more towards institutional clinics. With CPC+ and the move towards population management, the reimbursement for Medicare patients has never been better for private PCPs. Medicare and the insurance companies are seeing the financial benefit of good PCPs - keeping patients healthier by preventing disease and keeping the patients out of the hospital. They are starting to share part of this savings with private PCPs. Medicare is paying for more care coordination to assist the PCPs care for their patients
If there are these benefits for PCPs and Medicare, then why (in this area) are so many PCPs declining to accept new Medicare patients?

Interestingly, Medicare Advantage (MA) and Medicare Cost (MC) plans, though, in this are advertising a lot to attract Medicare folks.

Lynette
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Re: Please explain how Medicare Billing works? Update

Post by Lynette » Wed Aug 23, 2017 8:58 am

I haven't checked out fully what Medicare paid for my Welcome to Medicare but I gather that they paid for it partially - e.g. blood tests, etc. but not entirely as my doctor did not meet the full requirements as he knows me so well. The program is supposedly designed to test socialization, depression, education, counseling as well as diagnosis for physical diseases such as hypertension osteoporosis and cancer. As my doctor knows me so well it would have been totally silly to ask if I had friends or was keeping active. I got a questionnaire from AARP (United Health Care) that also asked those questions.

toofache32
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Re: Please explain how Medicare Billing works? Update

Post by toofache32 » Wed Aug 23, 2017 9:30 am

dm200 wrote:
Wed Aug 23, 2017 8:37 am
I disagree that Medicare patients will be moving more towards institutional clinics. With CPC+ and the move towards population management, the reimbursement for Medicare patients has never been better for private PCPs. Medicare and the insurance companies are seeing the financial benefit of good PCPs - keeping patients healthier by preventing disease and keeping the patients out of the hospital. They are starting to share part of this savings with private PCPs. Medicare is paying for more care coordination to assist the PCPs care for their patients
If there are these benefits for PCPs and Medicare, then why (in this area) are so many PCPs declining to accept new Medicare patients?
Because we've seen this before repackaged in other forms...you can only poison the well once. The benefits of the new plan are touted so doctors will join. Then the doctors sign up and pay tens of thousands of dollars of their own money to become "compliant" with the new regulations. At the same time, the new regulations are ambiguous and cumbersome enough that the insurance company denies payment with "gotchas". Remember, the first priority of insurance/Medicare is to find ways to minimize paying claims.

dk240t
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Re: Please explain how Medicare Billing works? Update

Post by dk240t » Wed Aug 23, 2017 10:29 am

Medical billing is the long game. Expect you can get it resolved but you should think on the order of months and years, not minutes and hours. Such is the case for all medical billing in the US now, not just Medicare.

They screw something up, you let them know, and wait till you get something from someone again. In the meantime, don't pay anybody money you don't owe them.

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dm200
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Re: Please explain how Medicare Billing works? Update

Post by dm200 » Wed Aug 23, 2017 10:39 am

Remember, the first priority of insurance/Medicare is to find ways to minimize paying claims.
One way to look at "insurance", but without a sufficient number of satisfied customers, "insurance" providers will lose business.

For example, in my Kaiser Medicare plan (about 7 years), I have never sensed that they refused (or seven "stalled") to provide proper addressing of medical conditions to save money. Neither have I sensed that with my wife (2 years). In fact, they often seem to sometimes go beyond medical necessity and promptness of being seen/treated. On one or two occasions, I have even "pushed back" at some tests (not cheap) they wanted to do that I thought were unnecessary.

toofache32
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Re: Please explain how Medicare Billing works? Update

Post by toofache32 » Wed Aug 23, 2017 11:04 am

dk240t wrote:
Wed Aug 23, 2017 10:29 am
Medical billing is the long game. Expect you can get it resolved but you should think on the order of months and years, not minutes and hours. Such is the case for all medical billing in the US now, not just Medicare.

They screw something up, you let them know, and wait till you get something from someone again. In the meantime, don't pay anybody money you don't owe them.
This is exactly the problem. "They screwed up" is arbitrary, inconsistent, not well-communicated, and defined by one side only while the other side has no reasonable nor timely recourse. Google "Contract of Adhesion".

dk240t
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Re: Please explain how Medicare Billing works? Update

Post by dk240t » Wed Aug 23, 2017 12:40 pm

toofache32 wrote:
Wed Aug 23, 2017 11:04 am
dk240t wrote:
Wed Aug 23, 2017 10:29 am
Medical billing is the long game. Expect you can get it resolved but you should think on the order of months and years, not minutes and hours. Such is the case for all medical billing in the US now, not just Medicare.

They screw something up, you let them know, and wait till you get something from someone again. In the meantime, don't pay anybody money you don't owe them.
This is exactly the problem. "They screwed up" is arbitrary, inconsistent, not well-communicated, and defined by one side only while the other side has no reasonable nor timely recourse. Google "Contract of Adhesion".
What is "this" in your sentence "This is exactly the problem"?

toofache32
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Re: Please explain how Medicare Billing works? Update

Post by toofache32 » Wed Aug 23, 2017 12:52 pm

dk240t wrote:
Wed Aug 23, 2017 12:40 pm
toofache32 wrote:
Wed Aug 23, 2017 11:04 am
dk240t wrote:
Wed Aug 23, 2017 10:29 am
Medical billing is the long game. Expect you can get it resolved but you should think on the order of months and years, not minutes and hours. Such is the case for all medical billing in the US now, not just Medicare.

They screw something up, you let them know, and wait till you get something from someone again. In the meantime, don't pay anybody money you don't owe them.
This is exactly the problem. "They screwed up" is arbitrary, inconsistent, not well-communicated, and defined by one side only while the other side has no reasonable nor timely recourse. Google "Contract of Adhesion".
What is "this" in your sentence "This is exactly the problem"?
The part I highlighted in red. Now on reading it again I think you referred to "they" as the office. I (perhaps incorrectly) interpreted it to mean the insurance company was saying "they" (the provider's office) screwed something up and they (insurance) does nothing but wait for repetitive appeals and don't pay anything.

I apologize if this strayed off topic. My point relating this back to the OP's original issue is that medical billing is incredibly more complex than most people realize. There are many folks who think providers just send a bill to insurance and it gets paid every time.

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