Medicare Experts (medical, plan, hospital, doctor)

[AADAD]

We are just now getting into our first set of bills from medicare. Many denials. Does anyone use a fee for service expert or website to sort out the medicare bills?

Thanks in advance.

[Ariadne22]

Originally Posted by AADAD

We are just now getting into our first set of bills from medicare. Many denials. Does anyone use a fee for service expert or website to sort out the medicare bills?

More information needed.

What type of coverage do you have? Are you on Original Medicare with a Medigap/Supplement?

Is Medicare denying these? If so, what is the reason?

These days "not medically necessary" is very common reason for denial which means the provider needs to resubmit the bill with more information and better coding. Happens all the time.

No one here has needed to employ an expert to navigate their Medicare issues because usually there aren't any - although there are services not covered by Medicare. If your needs are routine, that shouldn't be your issue.

[AADAD]

stated is "you do not have entitlement for this service". It was an MD visit. perhaps they don't know we have Medicare Part a and b?

[GreggT]

As already asked, original Medicare or an Advantage Plan?

[AADAD]

original medicare

[GreggT]

Bet where ever you received care, they coded it incorrectly. You need to go back to where you received care and ask for an explanation.
If you received care that was not Medicare approved, you need to find another doctor that is familiar with Medicare practices.

[Vivan22]

Originally Posted by AADAD

We are just now getting into our first set of bills from medicare. Many denials. Does anyone use a fee for service expert or website to sort out the medicare bills?

Thanks in advance.

Try and contact claimtherapist all your claims will be settled at an ease.

[AADAD]

Originally Posted by Vivan22

Try and contact claimtherapist all your claims will be settled at an ease.

I have filed an appeal to Medicare and cc'd pt financials at the hospital. It may be they did not know at that time that we had part B as we recently enrolled. They also are not paying as a coinsurance which is a little frustrating....we went out of network so primary employer only paid 50%. Medicare should pick it up but they did not....

[Ariadne22]

Originally Posted by AADAD

I have filed an appeal to Medicare and cc'd pt financials at the hospital. It may be they did not know at that time that we had part B as we recently enrolled. They also are not paying as a coinsurance which is a little frustrating....we went out of network so primary employer only paid 50%. Medicare should pick it up but they did not....

So, now, after two inquiries which were not answered, we learn you have employer coverage? With a network.

That is IMPORTANT information.

What you've just posted implies you are retired, enrolled in Medicare Parts A and B, have employer retiree coverage with a network - which means it is quite likely your retiree plan is an ADVANTAGE plan.

This means that although you are enrolled in Medicare Parts A and B, Original Medicare is NOT your insurer.

The employer Advantage plan IS your insurer - and this would account for why Medicare denied the claim, saying:

"you do not have entitlement for this service"

because you are no longer insured by Medicare. You are insured entirely (with exception of hospice and ESRD) by the employer plan. Therefore, there is no coinsurance to be paid by Medicare. Which means, when you are covered under an Advantage plan, YOU pay what the Advantage plan doesn't.

What is puzzling is why Medicare got bills for you at all. All bills should have been sent to your employer Advantage plan. Medicare is out of the picture. Sounds like the out-of-network provider was covering all bases and sent bills to both your employer plan - and Medicare, which should not have happened.

Know that under Advantage plans you are divorced from Medicare.

Instead, CMS pays the Advantage plan insurer a monthly a pre-negotiated capitation rate per enrollee - all bills go to the Advantage plan, the Advantage plan determines benefits and dispenses payment.

Therefore, if you have an employer Advantage plan, appeals to Medicare are without standing.

If the above is not relevant to your situation, please provide details on your employment status and specific employer coverage - and details on the medical service denied. Saying it is an MD appt. says nothing unless we know the exact purpose of that appointment. No one can help you if critical information is not provided.

[Ariadne22]

Reviewing your posting history and further to the above, it appears you may still be working?

If so, even though you are enrolled in Medicare, the employer plan is usually primary. Benefits are coordinated w/Medicare.

Medicare assigns designated reimbursement amounts for specific services. These allowed reimbursements are usually about 30% of what is actually billed.

Medicare will pay 80% of the reimbursement amount - provided that 80% has not already been paid by your primary plan.

So, look at the numbers. If your plan paid 50% to an out-of-network provider, it is highly unlikely Medicare's allowed reimbursement for a particular service would exceed that 50%.

Therefore, there would be no Medicare coinsurance component.

However, because Medicare stated: "you do not have entitlement for this service"

it is possible your employer is paying for a service not covered under Medicare at all - so Medicare isn't even making a payment determination.

And, again, with your employer as primary, it is highly unlikely Medicare will ever pay.

If your employer has more than 20 employees, your coverage with that employer is considered creditable. You could drop Part B while you are working and reenroll in Part B after retirement without penalty. If your wife is also of Medicare age and is covered under this plan, check with your employer first before dropping Part B for her.