Medical charges

[isisdave]

The problem with collecting the deductible is this:

You see Dr A on January 2, and he collects the deductible.

You see Dr B on January 12, and he wants the deductible too, because Dr A hasn't billed yet, or Medicare hasn't processed the claim, or whatever. It looks to Dr B like this is your first doctor visit of the new year.

Dr B has a great billing service that bills the next day; Dr A's gets around to it whenever. So Dr B's claim has the deductible applied, and Dr A's does not (on only partially, depending on how much Dr B billed).

That's why they usually wait to see what Medicare says, as refunding payments is way more trouble than collecting them. Usually.

 

[rapmarks]

The problem with collecting the deductible is this:

You see Dr A on January 2, and he collects the deductible.

You see Dr B on January 12, and he wants the deductible too, because Dr A hasn't billed yet, or Medicare hasn't processed the claim, or whatever. It looks to Dr B like this is your first doctor visit of the new year.

Dr B has a great billing service that bills the next day; Dr A's gets around to it whenever. So Dr B's claim has the deductible applied, and Dr A's does not (on only partially, depending on how much Dr B billed).

That's why they usually wait to see what Medicare says, as refunding payments is way more trouble than collecting them. Usually.

Yep, that’s what happened before my surgery in Feb. finally got the $700 back in August, and in September got a notice the practice filed for bankruptcy

 

[Talent312]

Speaking of refunds for insurance payments...
I recently got a $80 refund from an endodontist for
service 7 years ago. I asked, "Why, after 7 years?"

They said that an employee had embezzled a lot of
$$, and they did a forensic accounting that found it.
.

 

[simpsontruckdriver]

I'm pretty sure that to do so is not allowed under Medicare, if the provider "accepts Medicare."
Most commercial insurers would not permit that from an in-network provider, except when it is known that the deductible has not been met.
Even when I know that I'm going to have a $20 copay after Medicare Supplement, no one asks for it until "the dust settles" although they will accept it if I offer.

As a Medicare Insurance Agent (part-time) in FL, NC, and VA, this is somewhat allowed. Let's say your 20% coinsurance comes to $500 for a procedure. Medicare allows both MAPD and Supplement insurers to pass through another 15% to the insured (customer) if the provider needs it. It's possible the reason for the doctor requiring 100% up front is because the insurer is slow to pay.

For instance, let's say you worked as a real estate agent and just sold a $1,000,000 home to a CEO, and your commission is 15%. Your real estate firm says you'll be paid in 6 months for whatever reason. True, your commission is $150,000 but you have bills to pay from having no sales the previous couple months. That is probably what the doctor's office is looking at.

TS

 

[callwill]

Let me relate an insurance story...My wife is a private practice LMSW. Several years ago one of the insurance companies seriously over paid her by many many(10k+) thousands of dollars. When she contacted them, they didnt want to take it back, they instead wanted her to keep it and "work it off"! They told her they had no provision for taking back over payments! I do not know how it was ultimately resolved, but all i could say is that such things could really screw with your taxes.

 

[VacationForever]

As a Medicare Insurance Agent (part-time) in FL, NC, and VA, this is somewhat allowed. Let's say your 20% coinsurance comes to $500 for a procedure. Medicare allows both MAPD and Supplement insurers to pass through another 15% to the insured (customer) if the provider needs it. It's possible the reason for the doctor requiring 100% up front is because the insurer is slow to pay.

TS

Even for Supplement Plan F?????

 

[Sugarcubesea]

For this reason is why I opted for a supplement plan. This is not the first time I have heard/seen this type of thing happen

I will be going on Medicare in a few years, can you share how a supplement plan is better? All of my colleagues that have already retired told me to stay away from advantage plans as they all have had issues with them.

 

[dago]

Even for Supplement Plan F?????

I have Plan F. I believe Plan F covers overcharging. At least that is my understanding.

 

[Carolinian]

"No way to prevent this situation," says only developed nation where this kind of thing currently happens.

I think those using the private medical network in the UK rather than the NHS may also sometimes have to pay upfront. Most NHS senior doctors have private medical insurance so they can use the much superior private medical network instead of their own system.

I encountered something like that in Riga, Latvia. When an unknown substance that turned out to be pepper spray was spraying in my face in a robbery attempt, locals called an ambulance that took me to the emergency room. After evaluation and treatment, I was asked if I wanted to pay as I was leaving or if they should send somebody with me to get the payment. I asked how much, and everything, including the ambulence ride came to about US$20 so I paid them on the spot.

 

[Luanne]

I will be going on Medicare in a few years, can you share how a supplement plan is better? All of my colleagues that have already retired told me to stay away from advantage plans as they all have had issues with them.

The biggest problem I've hear of with advantage plans is that you have to stay within network. So if you are traveling and something happens you may be up a creek. They do seem to cover a lot, but you may also end up paying a lot out of pocket. My sister's SIL in MO said she is always having to pay something extra for whatever procedure she has. My husband and I both have Plan F, which is no longer offered. I think Plan G replaced it. So far, knock wood, we have not had to pay anything out of pocket. I had a hip replacement and cataract surgery, he has had a couple of surgeries as well.

 

[dago]

I will be going on Medicare in a few years, can you share how a supplement plan is better? All of my colleagues that have already retired told me to stay away from advantage plans as they all have had issues with them.

For me it's a personal choice. I am not saying a supplement plan is better for everyone. Both MAPD and supplement have their advantages and disadvantages. I may be over-insured, but I didn't want to go through the hassle of getting pre-authorization or worrying about going to in-network doctor/hospital. I didn't want to have to check each year to see if my doctors are in-network or dropped out.

I like the flexibility of the supplement plan. As long as Medicare covers the procedure my plan will cover the 20% that Medicare doesn't cover.

The last year of my MIL's life she had many medical issues in addition to her dementia (my spouse has dementia also). She was in and out of the hospital many times during that year and every time she had to go to rehab, we had to wait for approval from the insurance company.

I don't want to have to go through that.

The downside to Supplement is cost. Every year the premiums increase and now at my age (78) it's getting costly, but I can live with that. If you are living paycheck to paycheck and you are in good health, Medicare Advantage may be a good fit.
I can't recommend which one would be right for you. You need to read up on it and get educated. It can be complicated and overwhelming. Maybe talk to an independent insurance broker.

MedicareSchool.com may be a good place to start.

 

[Luanne]

When I became Medicare eligible our State Farm agent reached out to me. He wasn't trying to sell me their supplement plan (didn't even know State Farm offered one) but he did a really nice explanation of the various plans. When it came time for me to purchase a plan I used an independent broker that a friend had used. I've switched plans, through him, a few times, and currently have one that is quite affordable through Accendo (which is a CVS company).

 

[Carolinian]

With some insurers there is a real in-network / out of network scam. Our state has a dominant medical insurance provider, Blue Cross, and just about every doctor and facility is in their network. Others are more problematic, and you can get stung with them. An example is my wife's recent eye surgery. Her employer had switched their plan from Blue Cross to another carrier. Her eye doctor is in the new carrier's network, but when she needed a cataract surgery, we discovered that the main facility in that city where almost all outpatient surgery of all kinds is performed was not in their network, and so that would be a major expense. Working through the eye doctor, the insurancy company verbally said that would cover it as in-network and grant a waiver, but now they have billed it out of network. If we cannot get satisfaction, we are taking this to the state Insurance Commissioner.

 

[dago]

When I became Medicare eligible our State Farm agent reached out to me. He wasn't trying to sell me their supplement plan (didn't even know State Farm offered one) but he did a really nice explanation of the various plans. When it came time for me to purchase a plan I used an independent broker that a friend had used. I've switched plans, through him, a few times, and currently have one that is quite affordable through Accendo (which is a CVS company).

Yes. That was similar to my situation. I have changed providers (not the Plan(F) more than once and actually it's quite affordable for me. The reason I mentioned that it is costly is because for some people that can be the difference. I was aware of that and planned for that in my budget.

 

[Luanne]

With some insurers there is a real in-network / out of network scam. Our state has a dominant medical insurance provider, Blue Cross, and just about every doctor and facility is in their network. Others are more problematic, and you can get stung with them. An example is my wife's recent eye surgery. Her employer had switched their plan from Blue Cross to another carrier. Her eye doctor is in the new carrier's network, but when she needed a cataract surgery, we discovered that the main facility in that city where almost all outpatient surgery of all kinds is performed was not in their network, and so that would be a major expense. Working through the eye doctor, the insurancy company verbally said that would cover it as in-network and grant a waiver, but now they have billed it out of network. If we cannot get satisfaction, we are taking this to the state Insurance Commissioner.

Our daughter (not Medicare eligible) has a very good medical plan through her employer. It is with Blue Cross/Blue Shield. But she had some testing done that was at a company that was not in network. The first "bill" she saw (online) was for $15,000! I told her not to panic until she got a real invoice, but she got very proactive. She contacted both Blue Cross and the company who did the testing. Final result was that Blue Cross adjusted their payments since the test was ordered by her doctor, who was in network. Bottom line is it will cost her $100 out of pocket.

 

[sue1947]

The biggest problem I've hear of with advantage plans is that you have to stay within network. So if you are traveling and something happens you may be up a creek. They do seem to cover a lot, but you may also end up paying a lot out of pocket.

Advantage plans, like any other type, vary depending on what you buy. A higher premium plan may have no co-pays at all. It's what you prefer. In some cases, the copays are for items that are more discretionary; it depends on the details of the plan you sign up for.
As for out of network coverage; that hasn't been a problem. Both my mother and I have Kaiser advantage plans. She fell and hit her head out of state with no Kaiser facilities and, more recently, she had a stroke and the nearest hospital wasn't a Kaiser one. In both cases, I called to report it (there's a phone number on the medical card) and it was all taken care of. She ended up paying $400 for the week long stay in the ICU and I think some small fees for the head injury.
Everybody's issues/preferences etc are different so when it comes time, evaluate all your options for your circumstances.

 

[Sugarcubesea]

I have Plan F. I believe Plan F covers overcharging. At least that is my understanding.

Is Plan F, a Supplement or an Advantage Plan

 

[simpsontruckdriver]

Is Plan F, a Supplement or an Advantage Plan

That is a Supplement not available to anyone who enrolls in Medicare after 2015. It paid for everything, no matter the cost, all the person paid for was the (somewhat high) premiums. Anyway, Medicare Advantage with Prescription Drugs is regulated by CMS (Center for Medicaid & Medicare Services), it's $0 premium, you can choose an HMO (in-network only) or PPO (out-of-network higher price). PPOs are good for frequent travelers. HMOs are good for those who stay in their state, BUT if you travel, you can call and get in-network care out-of-state.

On the other hand, a Medicare Supplement is regulated by the state, several plans ("Part") are available depending on how much you want them to cover. Right now, the one that covers the most is Plan-G, which covers 100% after you pay your deductible (around $200). Premiums and whether or not they go up every year is up to your state.

TS

 

[slip]

As a Medicare Insurance Agent (part-time) in FL, NC, and VA, this is somewhat allowed. Let's say your 20% coinsurance comes to $500 for a procedure. Medicare allows both MAPD and Supplement insurers to pass through another 15% to the insured (customer) if the provider needs it. It's possible the reason for the doctor requiring 100% up front is because the insurer is slow to pay.

For instance, let's say you worked as a real estate agent and just sold a $1,000,000 home to a CEO, and your commission is 15%. Your real estate firm says you'll be paid in 6 months for whatever reason. True, your commission is $150,000 but you have bills to pay from having no sales the previous couple months. That is probably what the doctor's office is looking at.

TS

Mahalo for all your posts on this stuff over the years. My wife turns 65 in May and I will have to find someone here on Molokai to go over it all.

 

[dago]

Is Plan F, a Supplement or an Advantage Plan

Plan F is a supplement plan. It is no longer offered. Plan G is the closet alternative.
A supplement plan (AKA Medigap) is exactly what it is says. With a medigap policy you are covered by Medicare Part A and Part B. Typically Medicare covers 80%. You are responsible for the remaining 20%. Thats where the Medigap(supplement) comes into play. They all cover the 20%. Depending on what plan you have there may be co-pays and/or deductibles to cover.

Medicare Advantage is run by private insurance, and you won't be on original Medicare.

Please talk to an independent agent or read up on it at Medicare.gov.

 

[Talent312]

DW has Plan F and I have Plan G.
With Plan F, you pay -0- (other than your premium).
With Plan G, you pay the Part B deductible (and your premium).
With both, you walk out of a doctor's office or hospital w/o paying.

DW recently had a total knee replacement. She spent 5 days in the
hospital, 17 days in-patient at a rehab facility, and is now doing PT.
Total cost to her: -0-.

 

[VacationForever]

That is a Supplement not available to anyone who enrolls in Medicare after 2015. It paid for everything, no matter the cost, all the person paid for was the (somewhat high) premiums. Anyway, Medicare Advantage with Prescription Drugs is regulated by CMS (Center for Medicaid & Medicare Services), it's $0 premium, you can choose an HMO (in-network only) or PPO (out-of-network higher price). PPOs are good for frequent travelers. HMOs are good for those who stay in their state, BUT if you travel, you can call and get in-network care out-of-state.

On the other hand, a Medicare Supplement is regulated by the state, several plans ("Part") are available depending on how much you want them to cover. Right now, the one that covers the most is Plan-G, which covers 100% after you pay your deductible (around $200). Premiums and whether or not they go up every year is up to your state.

TS

I thought so, i.e. with supplement plan F (and G), doctor office CANNOT have 15% surcharge billed directly to the patient as you had stated in your original post in #29. https://tugbbs.com/forums/threads/medical-charges.356898/post-2978844

 

[SusanRN]

Medicare Advantage with Prescription Drugs is regulated by CMS (Center for Medicaid & Medicare Services), it's $0 premium, you can choose an HMO (in-network only) or PPO (out-of-network higher price). PPOs are good for frequent travelers. HMOs are good for those who stay in their state, BUT if you travel, you can call and get in-network care out-of-state.

TS

I have a Johns Hopkins Medicare Advantage PPO plan. I don't travel out-of-state anymore, but one particulare drug I take is much cheaper under the PPO plan, so compare their lists. The HMO plan is $0 for people who live in Baltimore City, but has a cost for those elsewhere in the State of Maryland.
I always stay in-network (lower cost), because I'm comfortable with any provider approved by Johns Hopkins. Most of my providers actually are employed by JH. I realize this is a unique situation, however.

 

[dago]

DW has Plan F and I have Plan G.
With Plan F, you pay -0- (other than your premium).
With Plan G, you pay the Part B deductible (and your premium).
With both, you walk out of a doctor's office or hospital w/o paying.

DW recently had a total knee replacement. She spent 5 days in the
hospital, 17 days in-patient at a rehab facility, and is now doing PT.
Total cost to her: -0-.

Same with me. I was in the hospital for 3 weeks after a surgery. Ran up a substantial bill and had 0 to pay.
To be fair
We need to include the cost of the premiums as out of pocket expense.
And remember there is no Part D(prescription drug) coverage.

 

[clifffaith]

Medicare supplement plans can deny your enrollment after X amount of time on Medicare. So if you already have medical issues, or anticipate them, you need to sign up for a supplement plan as soon as you are eligible for Medicare. A year before I was to go on Medicare we were sitting with an Aetna agent as Cliff changed from a Healthnet HMO to Aetna HMO. Everything I was hearing sounded good, for me the following year, but agent said “oh no, you have back problems, you’ll want a Supplement plan”. So I went direct to the AARP supplement plan.

Exactly one year later Cliff turns up with bladder cancer. A few weeks of getting approvals for every step turned him to an Aetna PPO. Then came our move, connecting with a clinical trial at UCI, and oh, sorry, either Aetna won’t deal with clinical trials or UCI won’t deal with them, or both. UCI says “here’s the names of two brokers, call one”. Broker says “Blue Shield has a moratorium on entering their supplement plan with a pre-existing condition, I’ll sign you up. And by the way in CA when you are on a supplement plan you can change plans every year on your birthday, so in two months we’ll change to Anthem for $100 less per month”. Done and done!