medicare denial-freaking out

[jsanders1379]

I am sort of freaking out right now-looked on the medicare website & saw that medicare had only paid $4,000 out of a $124,000 hospital bill for my GK- it said "some procedures may have been denied" under the "you may have to pay" column...what does that mean?

[arizonajack]

I am sort of freaking out right now-looked on the medicare website & saw that medicare had only paid $4,000 out of a $124,000 hospital bill for my GK- it said "some procedures may have been denied" under the "you may have to pay" column...what does that mean?

I suggest you start by getting complete statements of account from the hospital and your doctors to see exactly what procedures were billed to Medicare (and your supplement if you have one).

There's no way GK should have cost $124,000 especially if you were in and out on the same day.

I had a similar issue with my hospital. They billed the VA $85000 by including a $65000 charge for photon treatment in addition to GK when the hospital doesn't even have the facilities for photon treatment. The VA got the hospital bill audited (which means comparing the billed items to the medical records) and out of the remaining $20,000 in pure cost, paid about $10,000 under contract. I believe that providers' contracts with Medicare are similar to providers' contracts with the VA.

So the first thing you have to do is find out what hospital charges were bogus.

Unfortunately, you're going to have to be proactive and aggressive.

Took me a couple of months to get it resolved.

[robinb]

Hi Jeanne-

Don't freak out; I am sure they did a pre-authorization before your treatment.

I am over 4 mos post GK and hospital still working out charges w/my insurance. In the meanwhile, I have only paid $60 for my copay for consult and $10 for lab work.

I wont pay anything else till sorted thru. At the end of the day, I thought I would owe about 5k, but will likely be less than 2k for my out of pocket.

The total billed to my insurance was about $60,000 which gets whittled down to the agreed upon rate for in network providers and hospitals.

The first bills of $54,000 were mistakenly applied to my husband, then took a month for them to realize the screw up so now they are redoing everything. They denied the MRI and radiologist fees as "experimental" which just took a phone call to get them to resubmit.

If you just had it done, I recommend letting hospital and insurer work thru everything first and then when they present you w/final bills then you can dispute. Of course, I am no medicare expert, I have Anthem BC/BS.

At any rate, focus on your recovery and yourself at this point.

How are you doing?

[jsanders1379]

thanks Robin-I'll follow your advice-the only thing medicare indicated they "denied" was a $45 charge for something not clearly specified...guess I'll calm down & "Wait & Watch" once again...I'm doing OK-lots of ups & downs with mild dizziness and some headaches...

[LakeErie]

I don't know if this applies to your situation or not, but in my case hospital bills were "denied" by medicare because they were billed incorrectly. Billing incorrectly can mean wrong claim numbers for procedures were used by the provider, or inadequate substantiating information for determining medical necessity was missing. In my case, the hospital sent copies of the surgeon's file notes to Medicare and the claim was approved, but it took almost 6 months to resolve. Also, the billing department of my hospital reworked claim forms after Medicare notified the hospital of the incorect billing procedures and provided the correct billing numbers.
You can call Medicare and a representative will discuss your claim with you and tell you exactly where everything stands. I have done this myself.

[arizonajack]

guess I'll calm down & "Wait & Watch" once again

I wouldn't.

[james e]

Government healthcare...how's that working out for you?

[arizonajack]

Government healthcare...how's that working out for you?

You talkin' to me?

Cause for me it works out fine.

[jsanders1379]

Actually it's working fine, I guess...finally got a live person on the medicare phone line & they told me my hospital was contracted with them...so even though the hospital billed $124,000, Medicare only allowed about $8,000 and I'm only responsible for about $1300....

[james e]

No, I'm not talking to you...just tired of the government getting involved in our lives. I am a Viet Nam vet, and I know about the VA...glad we have it...for veterans. Just leave everyone else alone. This is not really the place  to argue the point.

James

[jsanders1379]

Only  veterans? Not for ex-Peace Corps Volunteers?-I feel like I served my country too....

[james e]

The VA is specific for military veterans. There are soldiers, airmen, and sailors who will never recover from their wounds, mental and physical, and they will need the support of their countrymen, and I am more than willing to support them.  I am fully recovered, but some of my friends are dead, some wish they were, and others are still suffering. Big difference between the military and the Peace Corp. I salute your dedication to the PC, the USA, and everything you did to benefit your fellow mankind. We need more of you.

James

[chloes mema]

Jeanne

I have Medicare, for 2011 & 2012 the total cost of my AN billed to Medicare was $148,984 of which they paid $13,756.  My supplemental insurance paid $4,278.  Now some where, some one absorbed the difference but it wasn't me!  Go figure.  That total included numerous MRI's, doctor appointments, and CK. 

I've notice this year that Medicare has put that notice on almost all my bills that have been submitted, when I go look at the bills it's denying payment of items such as "checking existing medication", "checking alcohol use", and other 'ridiculous' items listed but none of them have charges.  I think it's the "computer" program that's 'kicking' these out.

Good luck, keep track of what your billed & what has been paid by your provider and you.

Karen

[Crazycat]

The only way Medicare will cover the entire cost is for you to be on Disability. Outside of that Medicare works like most other insurance policies (deductibles), with the exception it is provided free of charge at age 65. This is why it is advisable to have a secondary or back-up, out-of-pocket insurance in conjunction with Medicare; and even then the deductible is not covered between the two of them.

[Jim Scott]

The only way Medicare will cover the entire cost is for you to be on Disability. Outside of that Medicare works like most other insurance policies (deductibles), with the exception it is provided free of charge at age 65. This why it is advisable to have a secondary or back-up, out-of-pocket insurance in conjunction with Medicare; and even then the deductible is not covered between the two of them.

Paul ~

An accurate description of Medicare. 

There is almost always a deductible and/or co-pay involved, whether you have Medicare, a Medicare supplement, employer-subsidized or 'private' health insurance.  In short, 'there is no free lunch'.  However, navigating the medical insurance jungle will get even trickier when the controversial PPAACA kicks in on January first, 2014. 

Jim