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Robyn and family have been Medicare patients of Mayo JAX for many years, and for the past few years she/hubby have been concierge patients of Mayo, as well.
Balance billing on the excess isn't the issue. What Robyn means is if Medicare denies payment on a service provided by Mayo - regardless if Mayo submits the bill to Medicare and Medigap as a courtesy (which courtesy Robyn has often mentioned on this board for a few years now) - Robyn still has to pay Mayo, anyway - and it's up to Robyn to fight w/Medicare (or maybe get Mayo to code differently) on the denied payment.
So Robyn's view is - contrary to the poster who said she would never pay a denied Medicare charge - since she (Robyn) isn't seeing docs who accept assignment - she will have to pay Mayo for any Medicare denied charge and try to collect directly from Medicare. Presumably, the poster to whom Robyn responded is seeing a participating provider who accepts assignment. Mayo doesn't - so if Medicare denies, it's all on Robyn.
Yes - that is what I'm saying. I do see a couple of doctors who "accept Medicare". Like a plastic/cosmetic surgeon. If something may or may not be covered by Medicare - the doctor's office gets an "advance ruling" from Medicare before a procedure (which in my case is never an emergency). That the procedure is or isn't covered. If it's covered - I sign a piece of paper that says I don't have to pay anything. And - if something isn't covered (although that hasn't happened to me yet) - I would have to pay "cash in advance" (or make some other payment arrangements). I see another doctor - an ENT - who works the same way. I honestly don't recall dealing with any doctors - whether for me - my husband - my father - or my late FIL - where we didn't know in advance exactly how much we might owe in non-covered expenses for anything. Robyn
The point I was trying to make guys is that so many errors are made by billers and by insurance companies on processing that you should never pay anything without calling both the insurance company and provider to clarify why you are being billed. If it doesn't sound right, ask to speak to a supervisor. Sometimes I wind up hanging up and calling back to speak to someone else if it still doesn't sit right.
I have witnessed thousands and thousands of dollars of medical billing errors sent to my parents over the past 10 years. Some of the bills they were sent were terrifyingly large. Almost all of them were mistakes. Some flagrant, some near fraudulent, some just basic human errors. I realized that many many seniors were getting bills like my parents were, and I'm sure some of them were paying them without realizing they were mistakes.
There are obviously some people on this site who are sophisticated about health insurance etc.., but many are not. The OP is clearly not experienced with Medicare.
To the OP - please look at the link I provided and look at the example of the ABN. You have to educate yourself. By looking at the form, you will probably remember if you signed one like it because it is unique. If you don't remember, memorize it now.
You can call Medicare now. They have customer service reps available 24 hours a day, 7 days a week. Ask them why they denied the claim. Tell them that you have been billed for the scan.
From what you describe, I suspect your primary care doctor didn't write sufficient diagnoses codes on the original CT scan order. That is very easy to fix. Call his office on Monday and ask to speak to his billing department and tell them what Medicare said about the claim. Then ask them to contact the doctor to correct any errors or get sufficient codes. That is usually easier than trying to ask the doctor yourself.
I agree with your suspicion. And the way to deal with it if it's correct. Keeping in mind what toofache32 said. That doctors often know zero about this stuff. The billing department will usually come up with the correct billing codes - and tell the doctor what to do (assuming it's simply a billing code error).
FWIW - all our ABN notices are printed on bright colored paper. So they stand out. And we really don't get that much paper these days. Most things are on line (except things we have to sign - like ABNs - consent forms - and the like). Robyn
I figured I will wait til Monday, I assumed that many probably were off today. I don't know exactly what I signed, it was back in September. But it was something to the effect that if insurance does not cover I am liable for it. I know one of them stated what it would cost if insurance did not pay. They make you sign so much stuff it's a bit much these days. Coming from an HMO world all I needed was my referral and I was good to go, the bill had to be paid.
The first CT was of my chest and they discovered kidney stones. They sent me to a urologist and he did a kidney stone CT of my urinary tract. Both CT scans were denied but the urologist resubmitted and got paid. But my primary Dr did nothing after the denial. And these tests were in Sept. My primary Dr is a big organization and it takes 6 months before you see a bill from them.
The 120 days I was referring to is if I want to appeal the denial. Let's say my primary Dr does not try and bill me for another 5 months. I won't be able to appeal the medicare denial. It's 120 days from the time I receive the notice from Medicare.
It's all new to me. Can I insist that a Dr get a precert for any MRI's or CT scans to help avoid these issues?
I thought getting prior approval from third party payers, ie insurance companies, Medicare for those scans (except in ER settings) was standard practice on the part of providers, to avoid these types of denials.
Depending on the reason for the scans, and the insurance company ( including Medicare, perhaps), I have seen insurance companies insist that patients have other testing, treatment, or even physical therapy done and failure of these measures documented before they will approve a CT scan or MRI. Often it doesn't make sense for them to do this when they will likely pay out more for these measures and especially when a scan is clearly indicated the patient will have to have it done anyway, but there it is. As I understand it insurance companies believe scans are overused and are a source of fraud. So there is more scrutiny for scans, and denials if this process, including prior approval, is not followed.
I don't know if this applies in your case, OP. But in your shoes I'd contact Medicare and get specific reasons for the denial- your doctor's office (probably billing department) can help you with this. The denial may be due to either lack of a piece of information Medicare wanted from your doctor, or perhaps an incorrect diagnosis or procedure code, anything. This can be corrected and resubmitted if this is the case.
If it is a matter of not getting a prior approval for the scan, perhaps you can appeal, but your doctor's office folks should have known if this was required and taken care of it.
I agree with your suspicion. And the way to deal with it if it's correct. Keeping in mind what toofache32 said. That doctors often know zero about this stuff. The billing department will usually come up with the correct billing codes - and tell the doctor what to do (assuming it's simply a billing code error).
FWIW - all our ABN notices are printed on bright colored paper. So they stand out. And we really don't get that much paper these days. Most things are on line (except things we have to sign - like ABNs - consent forms - and the like). Robyn
I know I have signed any number of ABN notices in my time, but honestly don't think I have had to do so for any of the doctors or other providers I have seen since I went on Medicare. All of these providers accept Medicare assignment, maybe that makes a difference.
Maybe it's because there are so many senior citizens on Medicare in this neck of the woods, but from what I can see the docs and other providers here take pains to ensure that they dot all their i's and cross their t's to prevent Medicare denials, and are most helpful in the event something like that comes up. They also seem to keep up with changes in Medicare rules,,and know just what they need to do to ensure the maximum reimbursement for any patient encounter.
I'd say it was because they know which side of their bread is buttered, but it also looks like Medicare reimbursements are decreasing over time, and my daughter, who works as a nurse in a large physician practice in the area, also talks about Medicare denials for things they had always covered, and having to jump through more hoops to get prior approvals-which she also says are denied more than previously. It's not justMedicare, it's also insurance companies, she says.
I called Medicare earlier today and I did not get many answers. I asked about why it was denied and got the stock answer insufficient documentation to justify the CT.
What I wanted to know was the time frame for this 120 day max appeal process. If the Dr resubmits does that reset the 120 days or is it from the original claim? They did not know.
So Monday I will call the billing department and see where that goes. I don't like this system at all. These expensive scans should require a pre-certification. Obviously from now on I will just refuse to sign that insurance liability clause, ABN form or anything else similar. It will be interesting to see if they refuse to perform the procedure then.
So you got the answer. The doctor needs to add more codes.
If you don't like the answer you get when you call Medicare.... if you want more detailed advice/information or if the customer service agent seems dismissive, ask to speak to a supervisor. The supervisors also have supervisors! You can keep going up the chain, which is sometimes necessary in complicated situations, until you get the information you need. The downside of doing this is you often are put on hold. I have had several phone calls to Medicare that have been very very very very long.....
Fortunately, as you become more experienced with Medicare this will become routine. If you realize that you go to a clinic that often makes mistakes with filing claims, you may have to deal with this more often. My Dad mostly goes to major hospitals now for his care, and they don't make many mistakes.
The clinic probably did call Medicare to get a pre-cert. But they can still make mistakes when they file the actual claim. You can ask the billing office if their standard procedure is to get pre-cert.
But as I said.... mistakes still happen when claims are filed by providers. All. the. time.
Also, all of the codes (ICD-10) just changed, so it is even more complicated for billing offices and providers. If they submitted the claim with the "old" codes (ICD-9), it is possible that Medicare just rejected it because their computers no longer will "recognize" the old codes.
My Dad used to see a doctor who had his own nurse and lab for blood tests. This doctor was often very sloppy when it came to putting the right codes on the order forms before sending my father for blood tests. The nurses who draw blood would enter the tests in their computers, and know right away if Medicare was going to reject the tests for not enough codes. So I started to put together a list of all the codes that my Dad needed..... all the diagnoses he had.... that would justify the tests he routinely needed. The nurse kept the list, and checked with the doctor. We worked together to make it work.
Yes - if the doctor re-submits the claim then the appeal clock will re-set. A new Medicare summary notice will be processed and sent to you, with a later date of processing on it.
Maybe over the next year, keep an eye on your Medicare summary notices just in case this clinic has a tendency to make mistakes. You can try to nip the mistakes in the bud early by looking at your notices, calling the clinics right away if you notice a claim got rejected.
And with regard to appeals of Medicare rejected claims...... It is nearly impossible to win an appeal with Medicare, unless they make a mistake on evaluating a claim and you are just alerting them of an error. There are many things that Medicare simply doesn't cover. These are sometimes things that other private insurance plans do cover, so it can be surprising. These exclusions sometimes do not make sense. But logic does not always rule at Medicare......
The last time I attempted an appeal it was for a medical supply that my father will need every month until the day he dies. I figured it was worth a fight since the cost would be quite significant to him over a lifetime. I went through 3 levels of appeal..... Lost the first decision... so appealed that.... last the second decision... so appealed that..... Each level of appeal has a different name. But then I finally won! It took more than a year. Maybe 1 year and a half. Many times the paperwork I sent would be "lost". I would have to call and call and call to push things through. By the time I won, I decided I didn't have the patience to do that again.... They wear you down.
I thought getting prior approval from third party payers, ie insurance companies, Medicare for those scans (except in ER settings) was standard practice on the part of providers, to avoid these types of denials.
Depending on the reason for the scans, and the insurance company ( including Medicare, perhaps), I have seen insurance companies insist that patients have other testing, treatment, or even physical therapy done and failure of these measures documented before they will approve a CT scan or MRI. Often it doesn't make sense for them to do this when they will likely pay out more for these measures and especially when a scan is clearly indicated the patient will have to have it done anyway, but there it is. As I understand it insurance companies believe scans are overused and are a source of fraud. So there is more scrutiny for scans, and denials if this process, including prior approval, is not followed.
I don't know if this applies in your case, OP. But in your shoes I'd contact Medicare and get specific reasons for the denial- your doctor's office (probably billing department) can help you with this. The denial may be due to either lack of a piece of information Medicare wanted from your doctor, or perhaps an incorrect diagnosis or procedure code, anything. This can be corrected and resubmitted if this is the case.
If it is a matter of not getting a prior approval for the scan, perhaps you can appeal, but your doctor's office folks should have known if this was required and taken care of it.
Most patients are amazed to learn that pre-authorization from the insurance company does not mean they will pay for it. At the bottom of every insurance pre-authorization is the fine print "Pre-authorization of services is NOT a guarantee of payment." In other words, they reserve the right to change their minds later.
I thought getting prior approval from third party payers, ie insurance companies, Medicare for those scans (except in ER settings) was standard practice on the part of providers, to avoid these types of denials.
Depending on the reason for the scans, and the insurance company ( including Medicare, perhaps), I have seen insurance companies insist that patients have other testing, treatment, or even physical therapy done and failure of these measures documented before they will approve a CT scan or MRI. Often it doesn't make sense for them to do this when they will likely pay out more for these measures and especially when a scan is clearly indicated the patient will have to have it done anyway, but there it is. As I understand it insurance companies believe scans are overused and are a source of fraud. So there is more scrutiny for scans, and denials if this process, including prior approval, is not followed.
I don't know if this applies in your case, OP. But in your shoes I'd contact Medicare and get specific reasons for the denial- your doctor's office (probably billing department) can help you with this. The denial may be due to either lack of a piece of information Medicare wanted from your doctor, or perhaps an incorrect diagnosis or procedure code, anything. This can be corrected and resubmitted if this is the case.
If it is a matter of not getting a prior approval for the scan, perhaps you can appeal, but your doctor's office folks should have known if this was required and taken care of it.
I'm not aware that any of my providers has gotten prior approval for CT scans. Also - I've never been asked to sign an ABN form for a CT scan or any other kind of form for a CT scan. Then again - I've only had 2 in my whole life. One about 6 years ago. One this year. One was pre-Medicare when I had a large deductible and was paying out of pocket (before reimbursement from an "excess" insurance policy). I had both of them when I had symptoms indicating the need for them (acute GI pain). And - if I had any questions about the need - I would ask my doctor why the need for one (considering the radiation and other risks).
The OP never mentioned what kind of CT scan he/she had - or what the indication for it was (at least in his/her mind). Perhaps some additional information might explain what happened here. Robyn
I was having severe back and side pains. He did an x-ray and saw nothing unusual. He was thinking kidney stones but I didn't think that was it since it was based on movement and I have had kidney stones in the past. He suggested I take Aleve for a couple of weeks and see how it goes. I waited about 6 weeks and it was no better. The pain was so bad I could not sleep in a bed, I was sleeping in a recliner. I went back to see him and he ordered a CT. The CT did show I had several small stones but none large enough to cause any issues, nothing else was found on the CT.
No smoking gun there best I can see in terms of the denial. Robyn
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