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My dad has medicare part b and secondary insurance blue shield.
Medicare didn't pay anything to provider. They bill secondary insurance blue shield who says it's experimental and patient responsibility is 0 on EOB. Medical office is contracted provider with secondary insurance.
Procedure code on EOB is 7557126
Patient responsibility: $0.00
(Amount you paid or owe to provider.)
Amount we paid: $0.00
Network savings: $175.00
(Amount saved by using a network provider.)
Amount billed by Provider: $175.00
Despite this doctor bills and says because they were denied he is responsible for the bill. Who is right?
What was the procedure? The code you gave appears to have too many digits. Did Medicare also deny because it is "experimental"? If so, neither will pay, but they cannot say the patient is not responsible. In fact, doctors usually have a Medicare beneficiary sign a form stating Medicare may not pay.
It does happen that not every medical service is an approved service under Medicare. Apparently, this is not a Medicare-approved service. Therefore, Medicare won't pay. If Medicare doesn't pay, then the Medigap won't, either. Medigaps will only pay their share of a Medicare-approved service. As Suzy says, the Medigap has no standing to say whether you are or are not responsible for payment for this service.
If Medical office did not have your father sign a form accepting responsibility for this service if Medicare didn't pay, your father may be able to get out of paying. Others here have. If, otoh, father signed a form accepting responsibility in the event of insurer nonpayment, then he's responsible for the $175.
What was the procedure? Did Medicare also deny because it is "experimental"? If so, neither will pay, but they cannot say the patient is not responsible. In fact, doctors usually have a medicare beneficiary sign a form stating Medicare may not pay.
Yes medicare denied it because it's experimental but so did secondary who is contracted with them. The procedure code that i see is only what i posted which is on EOB
12/16/19 Radiology
7557126 175.00 0.00 0.00 0.00 0.00 0.00 1
Claim Totals: 175.00 0.00 0.00 0.00 0.00
Notes
1 The service or item is identified in the Health Plan Medical Policy as investigational or experimental and therefore is not
covered. Upon request, the scientific or clinical judgment used for the determination will be provided to you, free of charge.
Your request should be submitted to us at the address or telephone number indicated on the front of this form
So while i understand that if medicare denies they can bill, how does that work when secondary in network insurance denies it as well?
Apparently, this is not a Medicare-approved service. Therefore, Medicare won't pay. If Medicare doesn't pay, then the Medigap won't, either. Medigaps will only pay their share of a Medicare-approved service.
It does happen that not every medical service is an approved service under Medicare.
Patient is responsible for this bill.
Explain why does EOB says patient responsibility is 0?
Explain why does EOB says patient responsibility is 0?
For clarity, I revised my earlier post after you posted. Please reread.
To restate, EOB from Medigap is worthless, because Medigap is not the primary payor. Medicare is. Medigap has no standing to say whether or not you are responsible for this service.
For clarity, I revised my earlier post after you posted. Please reread.
To restate, EOB from Medigap is worthless, because Medigap is not the primary payor. Medicare is. Medigap has no standing to say whether or not you are responsible for this service.
Interesting, will see how this goes for now. We are trying to fight it using what medigap says being they are their preferred provider.
Regular Medigaps don't have provider networks. This sounds like employer retiree health coverage - possibly FEHB through the govt? FEHB has many contracts w/Blue Cross. Nonetheless, Medicare is the primary payor and decider on what is and isn't a Medicare-approved service. Medical office billers should know this. That said, many medical offices write these charges off, rather than fight with the patient. Let us know what happens.
We are trying to fight it using what medigap says being they are their preferred provider.
Can you explain what this "preferred provider" is all about? I do know people have mistakenly assumed a medigap plan through a particular insurance company means their provider directory for individual plans also applied. A neighbor in my community had been picking their medical providers based on what was in-network and who was a preferred provider from the individual non medciare provider directory of that insurance company. That lead to all sorts of issues.
What was the procedure? The code you gave appears to have too many digits. Did Medicare also deny because it is "experimental"? If so, neither will pay, but they cannot say the patient is not responsible. In fact, doctors usually have a Medicare beneficiary sign a form stating Medicare may not pay.
This is an CT scan code to scan the heart. 75571-26. The 26 modifier is the professional component of the code to interpret the imaging results. The technical component is for acquiring the images. Insurance companies are notorious for saying anything they don't cover is "experimental" when they don't want to pay for it.
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