UHC/Medicare exclusion Dr Ayoola

[Starrfish]

I had what I hope is a quick question, that's been confusing. I have UHC PPO choice with what I was told is an exclusion for wls on my policy. I also have medicare (a&b). We were told by medicare it had to be submitted to UHC and receive a denial and have the surgery before they could process to medicare. Last I heard from Trevor was that he was submitting to UHC and a denial was expected by the end of the day, and I could then set my surgery date. Well, after not hearing from Trevor for nearly a week I called to check the status. Kayla read me Trevors notes on my file. It stated he had submitted the initial case, they replied requesting additional clinical info on my comorbidities, which he then submitted late Friday afternoon. Kayla couldn't tell me if it was UHC or Medicare that the notes where regarding. My confusion is after looking at my UHC plan and claims, my plan doesn't specifically state "excluded" but there has been nothing showing up in claims. Medicare doesn't do prior auths, so is it possible my UHC is reviewing my surgery? I'm sure some of this could be cleared up by Trevor, but it's near impossible to get him on the phone. Thanks in advance for the advice.

 

[southernlady]

@Starrfish I had UHC and a Medicare Advantage policy when I had my surgery.
Our UHC policy didn't require a 6 month pre-op diet but did require 5 continuous years of MO. Since I had fallen below into Obesity a couple of times during those five years, UHC denied me. But we went forward knowing that I qualified under my Medicare Advantage policy.

Sure enough, my claims were first sent to UHC which denied payment, then went to my Medicare policy that paid 100% except for a very small hospital deductible (less than $300) and my standard co-pays.

You say you have Medicare A & B. If it is a standard Medicare and not a Medicare Advantage policy, you do understand that typically they only pay 80% of the bill? If UHC denies you, then 20% falls on you. (Which is why I always had a Medicare Advantage policy). IF UHC approves it, then the remainder (after payment by UHC) goes to Medicare who pays 80% of what is is left. Example, say your bill is $100 and UHC pays $80. Then the remaining $20 goes to Medicare as a claim. Medicare pays $16 and you pay $4.00.

 

[Starrfish]

Yes, I understand that my straight medicare only pays 80% of what's not paid by UHC. This surgery came about very suddenly when I was diagnosed with IIH. so I didn't have time to signed up for an advantage plan, and never really needed or used my medicare previously.

I was more or less asking for thoughts or clarification on if UHC truly had an exclusion for wls on my plan, they wouldn't be requesting additional clinical info, correct? If it was medicare he was trying to submit to then they would just deny it as well since the surgery hasn't been preformed yet, correct?

 

[DianaCox]

You have a right to request and obtain a copy of the CONTRACT (generally called Evidence of Coverage) - not the summary of benefits, the WHOLE CONTRACT. Demand it from the insurance company if this is not an employer provided plan (if employer provided, ask HR).

 

[Spiky Bugger]

Hmmm...I was told--and it has been my experience--that Medicare is always primary...and my UHC PPO (not a supplement) is secondary to Medicare.

My billing ALWAYS goes to Medicare first. And if the provider screws up and bills UHC first, they always deny everything based on the fact that Medicare has to be billed first.

(I don't do Advantage because, to me, that means HMO...and I don't follow rules well enough.)

 

[southernlady]

If it was medicare he was trying to submit to then they would just deny it as well since the surgery hasn't been preformed yet, correct?

That I don't know since my Medicare Advantage policy did issue a per-authorization. for my DS. I always assumed that they (Medicare) just ignored the pre-cert sent from a provider and just paid the claim if the criteria was met.

Hmmm...I was told--and it has been my experience--that Medicare is always primary...and my UHC PPO (not a supplement) is secondary to Medicare.

Depends on your age and the spouse. While dh was gainfully employed (and I was under 65 myself...still there), my Medicare was secondary to whatever his employer had available (mostly UHC or BCBS). Once he went on disability himself, they swapped places. Once his COBRA disappeared, he and I both dropped to just Medicare. (both of us use a Medicare Advantage plan). We got very lucky, he was put on LTD on Feb 7th 2009 and they paid his/our COBRA thru to Dec 31st, 2011 at their expense not his.

And if the provider screws up and bills UHC first, they always deny everything based on the fact that Medicare has to be billed first.

(I don't do Advantage because, to me, that means HMO...and I don't follow rules well enough.)

All my doctors screwed up and billed Medicare first and were always denied. Didn't matter that I stood right there, handed them the cards IN ORDER and said "make sure that Medicare is billed secondary". They always messed it up. Which meant payment was ALWAYS delayed to them, even tho I tried to help.

I NEVER had a Medicare Advantage plan that was an HMO..I always got the PPO.

We actually use a Regional PPO thru Humana cause the only other PPO option in this county/state is BCBSNC and they mandate providers in state. Humana Medicare does a radius around your personal zip code...which is why all my doctors are in SC not NC. That area is closer.