Medical Insurance Frustration

[rhodesbe]

Oh man that is a subject that gets touchy here. I have a real messed up neck, I have been getting shots for almost 13 years so I can turn my head to the right. The surgery to TRY repairing the problem is very risky, then my EDS just makes it worse. But as of the new ocare crap going into effect my shots, most last 6-8 months, have been deemed "No longer medically necessary." Due to Medicare rules I can't even pay for them ($125) out of pocket or the Dr could get his license pulled.

Man, this sucks. Sorry to read this.

 

[tRidiot]

Oh man that is a subject that gets touchy here. I have a real messed up neck, I have been getting shots for almost 13 years so I can turn my head to the right. The surgery to TRY repairing the problem is very risky, then my EDS just makes it worse. But as of the new ocare crap going into effect my shots, most last 6-8 months, have been deemed "No longer medically necessary." Due to Medicare rules I can't even pay for them ($125) out of pocket or the Dr could get his license pulled.

My guess is that he could afford to give them to YOU for that price... but if he did, he would be in violation of Medicare's policies because he bills them for much more. It's all part of playing the game, and the obliteration of the free market.

 

[JD8]

If a provider agrees to accept Medicare assignment, they also agree to perform procedures for Medicare's approved cost and cannot bill over and above that, even to a secondary.
Thanks .gov. Great work.

Right. A MED-PAR physician has to take assignment as full payment. However, Supplemental plans pay ALL the time for various claims as they cover the remaining 20%. Your Surgeon friend was likely covered by part A, in which a supplement covers the rest of part B or said 20%.

 

[EhlerDave]

My guess is that he could afford to give them to YOU for that price... but if he did, he would be in violation of Medicare's policies because he bills them for much more. It's all part of playing the game, and the obliteration of the free market.

The $125 is what was billed, to Medicare, I got the letter stating I can't have them anymore from Medicare, I asked about paying and they quoted a rule that a Dr can't take payment from me. If he accepts the Medicare payments, the woman said, that is to keep Dr's from charging people extra.

What I know is my neck hurts and turning to the right is a bad idea.

Sorry I know none of this helps the OP.

 

[tRidiot]

The $125 is what was billed, to Medicare, I got the letter stating I can't have them anymore from Medicare, I asked about paying and they quoted a rule that a Dr can't take payment from me. If he accepts the Medicare payments, the woman said, that is to keep Dr's from charging people extra.

What I know is my neck hurts and turning to the right is a bad idea.

Sorry I know none of this helps the OP.

That seems odd... that a physician who accepts Medicare is conversely forbidden to accept a private payer? I dunno, seems odd somehow.

 

[Brandi]

I feel for you, the current health/medical insurance system is as crooked and corrupt as any mafia family ever dreamed of being. You can play by the rules all your life and if they can find a way to screw you over they will. You can't really trust any industry that pays specialized teams to scour your claim to find any discrepancy that will allow them to deny your claim regardless if it relates to the claim or not. I can't count how many times I've had to deal with that kind of stuff, having a chronic medical issue makes you an instant target for insurance company antics.

I have no idea if they are screwing you over in this case, I'd trust the resident experts here. Good luck with your problems, I hope you get it worked out.

 

[Davs2601]

Awesome link....I searched the net and couldn't find what I was looking for. This is what I needed to help clarify the issues.

IN a nutshell BCBS is right IMO and I absolutely hate saying that because they are such a bassackwards company. Under the COB provision they are not required to cover something that is above and beyond what they state is customary for that procedure, typically, even if another company pays part of the claim. Protects them from double indemnity.

http://personalinsure.about.com/od/insurancetermsglossary/g/coordination-of-benefits.htm

FWIW, until recently I dealt with health care providers on a daily basis and typically their front office had no clue when it came to claims, billing, what the law says, and policy coverages. So take what they say with a grain of salt. You should be able to get some help from your HR or plan administrator.

 

[inactive]

That seems odd... that a physician who accepts Medicare is conversely forbidden to accept a private payer? I dunno, seems odd somehow.

Not only that, but medicare denied it. If he elects to pay cash, that doesn't set any precedent that Medicare should or should not pay for them in a given circumstance, or what the price would be. Just that the patient elected to a treatment not covered by Medicare. Pretty much anyone can seek treatment and agree to pay out of pocket outside of insurance as they and the provider see fit.

Something sound fishy about the doc. I may consider a second opinion.

 

[EhlerDave]

Not only that, but medicare denied it. If he elects to pay cash, that doesn't set any precedent that Medicare should or should not pay for them in a given circumstance, or what the price would be. Just that the patient elected to a treatment not covered by Medicare. Pretty much anyone can seek treatment and agree to pay out of pocket outside of insurance as they and the provider see fit.

Something sound fishy about the doc. I may consider a second opinion.

If I have the time tomorrow I will post the Medicare rules, being I am his patient and on Medicare I am not private pay. The Dr was not even aware of the medicare denial. The notified me first, but not sure. I know I have it in my Medicare book that if Doc takes Medicare Assignment he cant add on to that, therefore I am not allowed to pay for the shots myself. That is according to Medicare.

 

[tRidiot]

If I have the time tomorrow I will post the Medicare rules, being I am his patient and on Medicare I am not private pay. The Dr was not even aware of the medicare denial. The notified me first, but not sure. I know I have it in my Medicare book that if Doc takes Medicare Assignment he cant add on to that, therefore I am not allowed to pay for the shots myself. That is according to Medicare.

Yup, I'd be interested in seeing that citation. Thanks.