Medicare coverage process for new and rare treatment

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curmudgeon
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Joined: Thu Jun 20, 2013 11:00 pm

Medicare coverage process for new and rare treatment

Post by curmudgeon » Tue Dec 12, 2017 11:39 am

Note: This question is focused on the mechanics of Medicare coverage rather than any specific medical question, so hopefully it can remain an appropriate topic here.

FIL is looking to try a new treatment procedure (for Essential Tremor), and is a bit unsure of whether or how costs can be covered. My understanding is that they have some prior employer retiree medical coverage stacked on top of Medicare. I would have expected the procedure to be covered, but they seem to be actually planning to pay the whole thing out-of-pocket, (it won't be cheap). The procedure received FDA approval a couple of years ago, but there are still only 10-12 hospitals in the US which do this. In some searching online, I've seen a reference that Medicare has approved an "institutional payment level" for the (outpatient) procedure at approximately $10,000, set a year ago. He seems to be preparing to pay potentially a much higher cost directly (I can see where he might consider it worthwhile if the treatment is effective).

I'm a bit concerned that FIL may end up paying a quite high set of charges out of pocket when he perhaps doesn't need to be (since the treatment is no longer experimental). Are there any specific hoops or gotchas that he should be watching out for? Does he need to make sure that his in-processing is categorized in some particular way? Should they just submit the bills to insurance and medicare and wait for the dust to settle? Unfortunately I don't know the details of their insurance at this time.

earlyout
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Re: Medicare coverage process for new and rare treatment

Post by earlyout » Tue Dec 12, 2017 12:07 pm

Suggest you first call Medicare and talk to them about whether or not they pay for the procedure and how much they pay. If they do, your second call is to the provider for this procedure to find out if they accept Medicare assignment for the procedure. Also ask if the auxiliary providers -- hospital/surgery center, anesthesiologist, etc. accept Medicare assignment. Finally, call the retiree insurace company (it may be supplemental, secondary or even an HMO) and talk to them about what they will cover (with or without Medicare depending on what you learned from Medicare).

curmudgeon
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Re: Medicare coverage process for new and rare treatment

Post by curmudgeon » Tue Dec 12, 2017 5:34 pm

earlyout wrote:
Tue Dec 12, 2017 12:07 pm
Suggest you first call Medicare and talk to them about whether or not they pay for the procedure and how much they pay. If they do, your second call is to the provider for this procedure to find out if they accept Medicare assignment for the procedure. Also ask if the auxiliary providers -- hospital/surgery center, anesthesiologist, etc. accept Medicare assignment. Finally, call the retiree insurace company (it may be supplemental, secondary or even an HMO) and talk to them about what they will cover (with or without Medicare depending on what you learned from Medicare).
Thanks for that feedback. I still have a few years before Medicare eligibility, and so I haven't tracked this stuff much yet. I think their retiree insurance would be secondary, not an HMO. As I have dug deeper, I've found documents for several insurers saying that they consider the procedure "experimental", and won't cover it (that may change over time; the documents were a year or so old). Interestingly, they do cover a different procedure, which seems both more expensive and more invasive, maybe it is a timing thing.

Even if they have to pay the medicare co-insurance, that would be much better than full out-of-pocket. It seems like the question of accepting Medicare assignment will be key.

carolinaman
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Location: North Carolina

Re: Medicare coverage process for new and rare treatment

Post by carolinaman » Wed Dec 13, 2017 7:50 am

curmudgeon wrote:
Tue Dec 12, 2017 5:34 pm
earlyout wrote:
Tue Dec 12, 2017 12:07 pm
Suggest you first call Medicare and talk to them about whether or not they pay for the procedure and how much they pay. If they do, your second call is to the provider for this procedure to find out if they accept Medicare assignment for the procedure. Also ask if the auxiliary providers -- hospital/surgery center, anesthesiologist, etc. accept Medicare assignment. Finally, call the retiree insurace company (it may be supplemental, secondary or even an HMO) and talk to them about what they will cover (with or without Medicare depending on what you learned from Medicare).
Thanks for that feedback. I still have a few years before Medicare eligibility, and so I haven't tracked this stuff much yet. I think their retiree insurance would be secondary, not an HMO. As I have dug deeper, I've found documents for several insurers saying that they consider the procedure "experimental", and won't cover it (that may change over time; the documents were a year or so old). Interestingly, they do cover a different procedure, which seems both more expensive and more invasive, maybe it is a timing thing.

Even if they have to pay the medicare co-insurance, that would be much better than full out-of-pocket. It seems like the question of accepting Medicare assignment will be key.
My former employer provides Medicare supplement. Generally, they will cover anything that Medicare covers (as supplemental insurance). If Medicare covers it, your friend's secondary insurance will likely also cover it.

afan
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Re: Medicare coverage process for new and rare treatment

Post by afan » Wed Dec 13, 2017 8:31 am

If your FIL has identified several places that offer the procedure, contact them and ask about coverage. They will have people whose full time job is dealing with Medicare and private insurance. They will know. Depending on the procedure and the private insurance it might be covered in some places and not others.
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ResearchMed
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Re: Medicare coverage process for new and rare treatment

Post by ResearchMed » Wed Dec 13, 2017 9:48 am

curmudgeon wrote:
Tue Dec 12, 2017 5:34 pm
earlyout wrote:
Tue Dec 12, 2017 12:07 pm
Suggest you first call Medicare and talk to them about whether or not they pay for the procedure and how much they pay. If they do, your second call is to the provider for this procedure to find out if they accept Medicare assignment for the procedure. Also ask if the auxiliary providers -- hospital/surgery center, anesthesiologist, etc. accept Medicare assignment. Finally, call the retiree insurace company (it may be supplemental, secondary or even an HMO) and talk to them about what they will cover (with or without Medicare depending on what you learned from Medicare).
Thanks for that feedback. I still have a few years before Medicare eligibility, and so I haven't tracked this stuff much yet. I think their retiree insurance would be secondary, not an HMO. As I have dug deeper, I've found documents for several insurers saying that they consider the procedure "experimental", and won't cover it (that may change over time; the documents were a year or so old). Interestingly, they do cover a different procedure, which seems both more expensive and more invasive, maybe it is a timing thing.

Even if they have to pay the medicare co-insurance, that would be much better than full out-of-pocket. It seems like the question of accepting Medicare assignment will be key.
You might also want to check with the appeals section of the retiree insurer about this.
IF there is a more expensive and more invasive care that is covered, they might be willing to make an exception ("saves them money", after all...!), especially if the procedure is NOT generally considered experimental.

At one point, we were able to get an exception to a very expensive Rx that was limited but needed more than the limitation, based upon the fact (documented) that it would avoid far more expensive ER and hospitalization care. It took some assistance from the physician as well.

Good luck.

RM
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mouses
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Re: Medicare coverage process for new and rare treatment

Post by mouses » Wed Dec 13, 2017 10:18 am

afan wrote:
Wed Dec 13, 2017 8:31 am
If your FIL has identified several places that offer the procedure, contact them and ask about coverage. They will have people whose full time job is dealing with Medicare and private insurance. They will know. Depending on the procedure and the private insurance it might be covered in some places and not others.
This I have found to be generally true with sophisticated medical care. Every once and awhile a billing office is clueless, but generally they are experts about these types of questions.

InMyDreams
Posts: 370
Joined: Tue Feb 28, 2017 11:35 am

Re: Medicare coverage process for new and rare treatment

Post by InMyDreams » Wed Dec 13, 2017 11:25 am

afan wrote:
Wed Dec 13, 2017 8:31 am
If your FIL has identified several places that offer the procedure, contact them and ask about coverage. They will have people whose full time job is dealing with Medicare and private insurance.
+1

If a provider is asking him to sign an "Advance Beneficiary Notice", that should be a clue that they think Medicare is going to deny it.

There are reimbursement specialists whose job it is to work with insurance companies to make them see the light and agree to pay. You have to pay for their services, however. Ideally, the hospital's reimburse people do that work.

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