Medicare Summary Notice for Part B

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drawpoker
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Medicare Summary Notice for Part B

Post by drawpoker » Mon Jul 08, 2019 6:15 pm

Can anyone here (perhaps one of the helpful docs) explain this mystery to me?

Latest quarterly MSN is listing my recent PET scan as "denied", yet, almost on the same page, the radiology doc who read and then wrote up the report on that very scan is "service approved". (Amount provider charged $370; Medicare-approved amount $123.93; my Plan F picked up the rest)

There is no reason given anywhere why the "Nuclear medicine study with CT imaging.....technical charge" or the accompanying "Fluorodeoxyglucose f-18 fdg" (that's the plutonium stuff they shoot into you) is listed as "NO" under the column "Service Approved" The only footnote that is listed is "N", whose explanation is given as : You should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the "Maximum You May Be Billed" column.

What gives here? As reassuring as it sounds that I should not be billed, something seems fishy. If Medicare refuses to pay, and says I don't have to pay either, then who does? The provider eats this? don't think so. The amounts listed are $1,425 for the actual scan, $322.80 for the nuclear cocktail - total $1,747.80.

I don't get it. Have been on Medicare for five years - this is the first time I have run into a denial on a covered procedure with absolutely no explanation. The only thing I can come up with is that nearly all of the other Medicare claims that involved expensive diagnostic tests & were paid carried the footnote "this claim shows a quality reporting program adjustment".

Could it be the hospital who performed the PET scan neglected to comply with some "quality reporting program" requirements? Things a patient would know nothing about? The radiologist who did get paid to interpret the PET scan had the notation on his claim for being in this "quality reporting program" thing-y, that is partly why I am speculating that may have something to do with it.

Anyone? Ideas welcomed, except, please, no "call the 800 number for Medicare and ask them". Too sickly now for that time-wasting and often-futile exercise.

Jyb33
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Re: Medicare Summary Notice for Part B

Post by Jyb33 » Mon Jul 08, 2019 11:38 pm

I assume you're familiar with ABN issues.......but...it does sound like the kind of result you'd get if you did not receive or sign one.....??
(I'm referring only to the billing issue ....i.e., that you're "not responsible" for the "non-covered service"......)...(but I can't
comment at all on the coverage issue itself)..........You probably know more about ABN's than I do....so...what does
a MSN show, in other cases, when you're not responsible for paying, due to an ABN not being given to you or signed....? Just curious.

p.s. Don't people get MSN's right after each claim? (or, if no claims, then every few months)?

Topic Author
drawpoker
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Re: Medicare Summary Notice for Part B

Post by drawpoker » Tue Jul 09, 2019 2:09 pm

Jyb33, I was not given an ABN form to sign for this. When I first joined Medicare and went for the "free" screenings offered some of the doc offices did ask for ABN to be signed. Think they were protecting themselves if it turned out I had a counterfeit Medicare enrollment card, or something phony, since they had no prior patient history for me. Since those first few months, I have had a ton of Medicare claims over the years, being in poor health, and never saw another ABN form again.

Don't think there would have been any issue here about the ABN on this - the referral, diagnostic codes were all in order, Medicare clearly lists PET scans as a covered benefit, nothing ambiguous. Anywhere they accept Medicare - am not enrolled in a MA plan where I would have had to use providers within a certain network. So, am completely baffled at this, still hoping for a doc here to weigh in :idea:

To answer your other :?: - CMS sends out the MSN every 3 months by snail mail. People can sign up for online registration with MyMedicare online, check claims as soon as they are posted, rather than wait for the mailings, if they wish.

With my Plan F insurer, they send out mailings every time they pay a claim, it is not a monthly or quarterly schedule. So I can keep up with the Medicare stuff fairly easily. (That is BC/BS, dunno know how the other insurers handle their claim notices to subscribers)

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drawpoker
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UPDATE

Post by drawpoker » Wed Jul 10, 2019 8:59 pm

Well, got my answer today, as bizarre as it is.

Medicare rejected PET scan because it did not recognize the all-important, sacrosanct provider's NPI number on claim. And Why?

According to very helpful and sympathetic person I talked with in the UMMS billing office - UMMS screwed up when they decided to change their NPI numbers earlier this year, and did not transmit the new info to CMS/Medicare computers correctly.

Too make it even more strange, the billing clerk disclosed this problem started way back in March of this year, and, unbelievably, it has still not been corrected :shock: Said she has gotten literally hundreds of irate callers over this, just like me, who received their MSN mailing with zero explanations for the denials.

As if UMMS hasn't already had enough scandals/disgraced board members/on-going state/federal investigations/and just generally horrible publicity to hit the news this year :shock: - now this :( . According to the very nice lady who was helping me, she did warn I might get a bill for this in the near future. As, apparently, the UMMS software for billings currently has no way of linking to this issue. It will automatically generate invoices to go out in the mail to the patient when an insurer, any of them, Medicare or private, sends an official denial of claim.

She did offer an opinion that she could not fathom why CMS (Medicare) could not furnish this information to beneficiaries (incorrect NPI #) on the MSNs. Real simple.

Am inclined to agree. They seem to have letter codes/footnotes/ for all kinds of other situations/reasons/ why claims are denied. Would it be so difficult........ :annoyed :confused :x :( :o :!:

Jyb33
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Re: Medicare Summary Notice for Part B

Post by Jyb33 » Wed Jul 10, 2019 9:44 pm

But...just so you know IN GENERAL.....supposedly: you cannot be billed (or you don't have to pay)
for a "rejected/denied.." (or whatever its called) procedure/treatment/etc.. (regardless of the mysterious reason for non-coverage) if
you didn't receive or sign (in the relevant box) an ABN. I couldn't tell from you first reply to me whether you were aware of that....(and in
your first/original post you were wondering if you would be billed and who might be paying for it)..

p.s. but this RULE does not apply to the clearly listed tests/treatments/procedures (on medicare's website) that are labeled as never being covered by medicare.

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drawpoker
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Re: Medicare Summary Notice for Part B

Post by drawpoker » Wed Jul 10, 2019 10:37 pm

The whole ABN thing is a mystery to me, anyway. If a Medicare beneficiary is asked to sign one, and refuses, I imagine the doc/clinic/whatever/provider could decline to proceed with whatever the treatment is. Right? (Unless, of course, it was an emergency situation/life or death/ in which first responders and hospitals are required to provide service regardless of insurance)

LIke I posted earlier, in the very beginning, it all made sense. Docs/labs/ER's/etc might naturally be leery of brand new people on Medicare & their documents, fearing fraud/stolen identities/etc. So, knowing that whatever service I was seeking was a 100% covered procedure under Medicare, I had no fear of signing these silly ABN forms back in the day.

Now? Uh, uh. If any doc, or other provider, shoved one of those under my nose and demanding to sign, I would have to ask some serious questions first.

Correct me if I am misunderstanding this - But, if a Medicare beneficiary signs one of these, isn't that legally binding they are agreeing to pay the full freight in the event Medicare later denies the service/procedure/test/whatever/ ?

Jyb33
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Re: Medicare Summary Notice for Part B

Post by Jyb33 » Wed Jul 10, 2019 11:11 pm

drawpoker wrote:
Wed Jul 10, 2019 10:37 pm
The whole ABN thing is a mystery to me, anyway. If a Medicare beneficiary is asked to sign one, and refuses, I imagine the doc/clinic/whatever/provider could decline to proceed with whatever the treatment is. Right? (Unless, of course, it was an emergency situation/life or death/ in which first responders and hospitals are required to provide service regardless of insurance)

LIke I posted earlier, in the very beginning, it all made sense. Docs/labs/ER's/etc might naturally be leery of brand new people on Medicare & their documents, fearing fraud/stolen identities/etc. So, knowing that whatever service I was seeking was a 100% covered procedure under Medicare, I had no fear of signing these silly ABN forms back in the day.

Now? Uh, uh. If any doc, or other provider, shoved one of those under my nose and demanding to sign, I would have to ask some serious questions first.

Correct me if I am misunderstanding this - But, if a Medicare beneficiary signs one of these, isn't that legally binding they are agreeing to pay the full freight in the event Medicare later denies the service/procedure/test/whatever/ ?
I think that's partly true...(but there are a few possible boxes to check on the ABN)......but those are all issues not related to your current one (since you never receive ABN's anyway, in all those years)...but the best thing is to just google it (I learned all about ABN's in a few minutes by reading some of the the "credible" sources that popped up). ..and some doctors on this forum discussed them a few times.....
But as far as i know, it's "great" to not receive ABN's!!!...you don't have to pay.....(see above).

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drawpoker
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Re: Medicare Summary Notice for Part B

Post by drawpoker » Thu Jul 11, 2019 9:13 pm

Jyb33 wrote:
Wed Jul 10, 2019 11:11 pm

.......(I learned all about ABN's in a few minutes by reading some of the the "credible" sources that popped up). ..and some doctors on this forum discussed them a few times.....
Following your idea - did a quickie search on this forum for previous posts on the topic of ABNs.

And, sorry to say, really did not learn anything new :? Just kinda raises even more :?: :?: :?:

If the whole purpose of the ABN form is to inform Medicare beneficiaries that the proposed
exam/test/procedure/treatment/whatever doo-hickey has a high probability of being denied -- 2 things immediately come to mind:

#1 The patient is no longer covered under Medicare Part B because they didn't pay the monthly premium, let it lapse, so, any and all claims are going to be denied. (This is not a remote possibility. Not all Medicare beneficiaries have the premiums deducted from soc. security check. People that aren't drawing soc. security yet have to pony up the money themselves, using one of the payment options offered)

This scenario would explain why one of the physicians on this forum posted that he insists ALL his patients sign an ABN. Every single time. I think that is probably reasonable enough - as long as the patient is given a candid answer and explanation at the time. Right?

#2 No offense intended to any of our friends here in the medical profession - but - um -have to say this:
If I go to a new doc (specialist) for something due to some serious condition - and is as result of legitimate referral from another doc, and, this new doc is insisting on signing of the ABN, well, um, er, alarm bells are going to go off.

To me, maybe I am just too cynical, this scenario would strongly suggest that it is not the patient who might be suspect, but the doctor
Meaning, this provider may be quietly under some sort of current audit/investigation/Medicare irregularities/questionable practices/somesuch, and he/she fears Medicare reimbursements may be at risk of being suspended.

Jes say'in, ya know.........anyone else kinda wonder about this ...

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celia
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Re: Medicare Summary Notice for Part B

Post by celia » Thu Jul 11, 2019 9:58 pm

OP, There are lots of reasons Medicare could reject a claim:
* Materials for some procedure should be included in the price of the procedure itself but were billed separately
* The claim was previously submitted and paid but maybe the provider is now adding on an additional service that should have been originally billed (only the “new” part would now be paid and the rest rejected as duplicate billings)
* Procedure is too soon since last time it was done (eg, if getting a yearly colonoscopy/mammo, it is too soon since the last one, unless a medical reason was given why it needs to be repeated so soon)
* Inconsistent procedures are done near each other in time (a neck X-ray and appendectomy are done the same day)
* Diagnostic code for the procedure is not given.

It is best to read the footnotes for each denied claim as they usually tell why the claim was denied.

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drawpoker
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Re: Medicare Summary Notice for Part B

Post by drawpoker » Fri Jul 12, 2019 1:57 pm

celia wrote:
Thu Jul 11, 2019 9:58 pm
It is best to read the footnotes for each denied claim as they usually tell why the claim was denied.
Except - in this case - they didn't - becoming the origin for the thread.

Dantes
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Re: Medicare Summary Notice for Part B

Post by Dantes » Fri Jul 12, 2019 4:28 pm

Unless I missed something above, the OP's problems are due to the really exceptional incompetence of his provider, who for months has had incorrect data recorded with Medicare and has not corrected it - and yet feels free to criticize Medicare for not including a more informative error code.

How is the facility (UMMS, whatever that is) itself being reimbursed if they are not identifying the individuals providing the services? This doesn't make sense.

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drawpoker
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Re: Medicare Summary Notice for Part B

Post by drawpoker » Fri Jul 12, 2019 5:20 pm

Dantes wrote:
Fri Jul 12, 2019 4:28 pm
.....the facility (UMMS, whatever that is) itself being reimbursed if they are not identifying the individuals providing the services? This doesn't make sense.
UMMS is the (supposedly) highly esteemed, top-rated University of Maryland Medical System. Sorry if I did not make it clear but it was in one of their facilities where I had the PET scan done. So, they are the "provider", filed with Medicare to get paid, and now are the goofs who aren't getting paid timely because of this snafu with the NPI numbers.

As far as criticizing Medicare, why not? If they can provide letter codes with footnotes to explain just about every other reason for a denial, why not incorporate another code? One to represent "Incorrect NPI # provided" ?

Doesn't seem like a big deal - would save folks alot of anguish and worry when this screw-up happens

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