Labs are suddenly costly?

[Spiky Bugger]

Changed PCPs. I think someone screwed up coding. I am suddenly getting "NOT APPROVED" all over my Medicare EOB...and yet none of those items were previously disallowed. What a PITA.

Whatever the coding geniuses did, they did it such that:
Clotting time (as in Vit K-related stuff)
Coagulation assessment
Vitamin D3
Vitamin A
New Patient Visit, since it WAS my first visit...

were all disallowed.

Do I start by complaining to the billing office?

AARGH!

 

[Munchkin]

Sounds like coding to me!

 

[Spiky Bugger]

Medicare dude concurred. Insufficient info to establish that medical necessity exists.

Also, there are a couple of charges that I allegedly don't have to pay because nobody told me that those tests weren't (usually) covered. Only...they DID. I signed the form saying I knew I might have to pay. I did that because previous tests had proper coding so they were always covered. Apparently, they have no record of my having signed it.

(I'm gonna get it all coded correctly because they will find that form two days before the one year cut-off and I'll have to pay. Better safe than sorry.)


.

 

[DianaCox]

OMG - is the denial from the insurance company or Medicare proper?

 

[Spiky Bugger]

OMG - is the denial from the insurance company or Medicare proper?

I have plain old Medicare as my primary (not an advantage program, not an HMO) and United Health Care PPO, a true secondary. This stuff is on the Medicare EOB and that guy was very helpful. It hasn't landed at the insurance company, UHC, yet.

AND this F'd up coding/billing is by a HealthCare Partners group. They ought to know better...AND my concierge doc was also HealthCare Partners affiliated and all of the same tests were billed correctly and should be in the system.

SOMEONE JUST GOT DAMNED SLOPPY!!

 

[southernlady]

Yeah, someone got sloppy. Hope you get it sorted out ASAP and re-billed under the correct codes.

 

[Psychomom]

If the labs are denied for non-covered service and no ABN was signed in advance, you are not responsible for the charges. Whoever performed the services eats the bill. If they did not bill the lab tests with the proper modifier showing an ABN was signed, the provider must appeal with medical records showing an ABN was duly signed and then Medicare will assign the amount of the lab to the patient. Plus--you are only responsible for the Medicare allowed amount--not the entire amount of the lab. If Medicare does not assign the debt to you, you are not responsible. This is where the Medicare biller does follow-up and appeals the claim with medical records and a revised diagnosis code and proper modifiers for your claim. If the Medicare biller does not do so, you are not responsible for any of it. Let them fight it out for you. That's what they get paid for. It never should have been billed with non-approved diagnosis codes in the first place. Plus, if they lost the ABN you did sign, it's as if you never signed one. I would seriously consider getting another PCP. If they lose and misdiagnose your records this easily, they will not be able to adequately take care of you. Everything is supposed to be on electronic records. If they cannot adequately store and recall the records on file, then they will not be able to look up information on you and could potentially endanger your life with missing and inaccurate records. What if you have a drug allergy and they do not have it properly documented and stored? They could give you a drug that could kill you. There is always the issue of having your records improperly stored under another indivual's name--not only are they not accessible to the doctor when he/she is treating you, potentially causing you to not receive necessary tests and care, it could cost the other patient hundreds to thousands of dollars when he/she comes in and unnecessary tests are ordered for him/her that are necessary for you. This is a bigger issue than just a misdiagnosed lab test.

 

[KathrynK]

I only have part A but the vitamin tests were done in the hospital. No test was covered. It was a $2200 bill. Thankfully, the reason I didn't get part B was because I still have my husband's insurance, so it was only $50 copay.

But the same week I got a $15,000 bill from the orthopedic surgeon, who refused to accept Blue Cross's customary payment. I was one month shy of Medicare when I broke my femur. I went to the emergency room, they handed me to this jerk, and they are claiming when I signed a document permitting them to bill the insurance company, there was a clause allowing them to refuse the insurance assignment. I didn't have my glasses, I was upset, and they were taking me into surgery and I couldn't find my husband. Crooks. The docs office says I can pay it off at $300/ month. Blue Cross says I can appeal the decision, but there's not much they can do. A car payment with no car. The hospital was paid and all the ancillary charges, except one radiologist who refused to accept assignment, and I had to pay him $450. This ortho guy preys on older women in the emergency room and probably drives a Mercedes. I would like to warn other patients by posting this experience online, but I am worried he would sue me.

 

[Spiky Bugger]

If the labs are denied for non-covered service and no ABN was signed in advance, you are not responsible for the charges. Whoever performed the services eats the bill. If they did not bill the lab tests with the proper modifier showing an ABN was signed, the provider must appeal with medical records showing an ABN was duly signed and then Medicare will assign the amount of the lab to the patient. Plus--you are only responsible for the Medicare allowed amount--not the entire amount of the lab. If Medicare does not assign the debt to you, you are not responsible. This is where the Medicare biller does follow-up and appeals the claim with medical records and a revised diagnosis code and proper modifiers for your claim. If the Medicare biller does not do so, you are not responsible for any of it. Let them fight it out for you. That's what they get paid for. It never should have been billed with non-approved diagnosis codes in the first place. Plus, if they lost the ABN you did sign, it's as if you never signed one. I would seriously consider getting another PCP. If they lose and misdiagnose your records this easily, they will not be able to adequately take care of you. Everything is supposed to be on electronic records. If they cannot adequately store and recall the records on file, then they will not be able to look up information on you and could potentially endanger your life with missing and inaccurate records. What if you have a drug allergy and they do not have it properly documented and stored? They could give you a drug that could kill you. There is always the issue of having your records improperly stored under another indivual's name--not only are they not accessible to the doctor when he/she is treating you, potentially causing you to not receive necessary tests and care, it could cost the other patient hundreds to thousands of dollars when he/she comes in and unnecessary tests are ordered for him/her that are necessary for you. This is a bigger issue than just a misdiagnosed lab test.

Thanks for sharing your understanding. Here's what I know so far...

1--ortho--I got double billed for an mri that had to be redone because they missed the part of the knee the ortho needed to see. He...nice guy, he carpooled to HS with a guy I dated back then and I put them in touch with each other...emphasized that there would be no charge. Under review.

2--some labs--doctor's office immediately recognized their coding error and are correcting it.

3--pcp--billing me as an existing patient instead of new patient, not an error, because my previous doctor was in the same group and billing is done under the same billing number.

4--other labs--well! HealthCare Partners and LabCorp have a new program for coding. AFTER MY LABS, but before today, HCP figured out that the software was coding ALL the dx codes as whatever the first draw was coded. Since CBCs and CMPs are near the top, almost everything was coded as routine testing and all "special stuff," like my complete iron and vitamins and PTH and INR...and everyone else's...was coded as routine and then disallowed. Being redone and resubmitted.

5--radiology--I have NO IDEA why the radiology place a) billed Medicare when they were apparently not a Medicare provider on 5/1/2016; and/or b) waited 14 months to bill anyone. I'm going to ignore that whole thing.


And we wonder why I take Lorazepam....lol

 

[southernlady]

5--radiology--I have NO IDEA why the radiology place a) billed Medicare when they were apparently not a Medicare provider on 5/1/2016; and/or b) waited 14 months to bill anyone. I'm going to ignore that whole thing.

Before ignoring, checks the laws of the states/federal involved for submitting in a timely manner. Health providers have to submit in a timely manner or the insurance company can tell them to eat it.

 

[DianaCox]

You may need to check this out. I'm about to turn 64, and my husband turned 65 last November, but I kept him on my insurance (I figured we'll go on Medicare together next year). We have a high deductible plan, so we have an HSA - and my Office Manager called me last week to notify me that they had made a mistake - that they should not have been allowing me to contribute to the HSA on behalf of my husband since he turned 65. BUT - we got the insurance broker involved, and she found this document (https://www.google.com/url?sa=t&rct...-B.pdf&usg=AFQjCNGFa3ASGPmRto37NVG0lC7ErziH0g) in which I saw this:

NOTE: If you qualify for premium-free Part A, your coverage will go back (retroactively) up to 6 months from when you sign up. So, you should stop making contributions to your HSA 6 months before you enroll in Part A and Part B (or apply for Social Security benefits, if you want to collect retirement benefits before you stop working).​

You should maybe find out if your Medicare part A started retroactively enough to cover your broken leg.

Oh, and yes, I can too continue to contribute to my HSA on his behalf, until *I* go on Medicare.

 

[southernlady]

You may need to check this out. I'm about to turn 64, and my husband turned 65 last November, but I kept him on my insurance (I figured we'll go on Medicare together next year). We have a high deductible plan, so we have an HSA - and my Office Manager called me last week to notify me that they had made a mistake - that they should not have been allowing me to contribute to the HSA on behalf of my husband since he turned 65. BUT - we got the insurance broker involved, and she found this document (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0ahUKEwjU6M3Fv8nVAhXnr1QKHalqDJsQFgg2MAI&url=https://www.cms.gov/Outreach-and-Education/Find-Your-Provider-Type/Employers-and-Unions/FS3-Enroll-in-Part-A-and-B.pdf&usg=AFQjCNGFa3ASGPmRto37NVG0lC7ErziH0g) in which I saw this:

NOTE: If you qualify for premium-free Part A, your coverage will go back (retroactively) up to 6 months from when you sign up. So, you should stop making contributions to your HSA 6 months before you enroll in Part A and Part B (or apply for Social Security benefits, if you want to collect retirement benefits before you stop working).​

You should maybe find out if your Medicare part A started retroactively enough to cover your broken leg.

Oh, and yes, I can too continue to contribute to my HSA on his behalf, until *I* go on Medicare.

But remember, while you may go on Medicare at the same time, it is not together as in one policy. You each will have your own policy. Medicare doesn't have family plans.

 

[Spiky Bugger]

Oh, and yes, I can too continue to contribute to my HSA on his behalf, until *I* go on Medicare.

But not if HE goes on Medicare, right?

http://www.investopedia.com/article...4/rules-having-health-savings-account-hsa.asp

Okay, and I'm not having private conversations with other Medicare beneficiaries, but they are certainly welcome to explain where I have gone wrong here.

Why the hell would you WANT a high deductible plan that you (or someone) probably pays a lot for, when Charles is now eligible for Medicare?

I might have been able to find a loophole and pay hundreds of dollars more per month and stay, for a while, on Mr. Sue's insurance as my primary...but WHY? Until he turns 65 in November, his primary is a PPO. My primary is Medicare (which covers 80% of charges) and I have a PPO policy, the same policy as his primary insurance, secondary to the Medicare (which covers 10-20% of charges) and it costs about $500-600/mo less than staying on his insurance as primary.

In November, when he gets Medicare and changes his PPO coverage to secondary to his Medicare, our monthly premiums will reduce several hundred more and our coverage will cost zero, other than the $100 or so each for Medicare. (The actual cost of his employer-provided policy for both of us under 65 would be $2800/mo. It dropped $800 when I went on Medicare, so $2k. Employer pays $1500 of that, so $500. It will drop another $800 in Nov when Mr Sue goes on Medicare. That covers all the premiums, except the actual Medicare premiums, and gives us 90-100% coverage for most everything...but not all specialty pharma. And no, we don't get a check for that leftover $300/mo.)

I guess what I'm not getting is why you seem to WANT to be responsible for high deductibles, even if they are tax advantaged, when you could have a far lower deductible with Medicare and not worry about deductibles. (My 2016 ANNUAL deductible was $166 and 2017 was $183. For those prices, I'll gladly lose the tax break. Unless...is there something I'm missing...like, do you get to keep whatever unspent money is in there when you retire...and if so, is your health...and Charles' health good enough to take that gamble?

Sincerely,

Confused

 

[KathrynK]

Thank you, Diana!! I will send the greedy surgeon to Medicare to see what they can get from them!!

 

[DianaCox]

"do you get to keep whatever unspent money is in there when you retire...and if so, is your health...and Charles' health good enough to take that gamble?"

Yes - can use it to pay Medicare premiums/copays for a while. I've got about $8K (pre-tax) in it.

I want us to go to the same doctors. I'm probably underthinking this, but I figured that whatever Medicare Advantage plan we buy, it would be easiest if we were on the same plan.