Question
I am a mental health provider in Louisiana with a provider contract with Humana and Corphealth, Humana's subsidiary covering mental health claims. I was already a provider with Humana when in 2007 I was made aware of their Medicare Advantage plan. I immediately contracted with Corphealth to work with Humana Gold Plus HMO since I was already working with many Medicare clients. Starting with the first claim I submitted in January of 2008, I have had every claim denied for payment by Humana with the denial being because I did not have a referral from the Primary Care Physician. I called Humana to inquire about the denials and I was told in Louisiana there is no requirement for the referral. We are the only state with this exclusion. (I recently found out this is because of Hurricane Katrina--LA residents were scattered across the country and could not get to their PCP's for referrals). So, I make a call when I received the denial and a claims rep states "you are right--you do not need a referral." The claim is resubmitted and paid about 2 weeks later. Again, I go through this with every claim! Now, in April, something changed. No, they did not fix their system to accommodate their own policy. They stopped fixing my claims and stopped paying. I have called provider relations, claim specialists for both companies. Yes, I am right, I do not need a referral. Please re-submit your claim but send it directly to this fax number and it will be taken care of. No, send it to this fax number. No payment received and further denials. It is now the end of August and I still have claims from April unpaid. So, I get tired of this runaround and contact the Insurance Commission office for Louisiana. They refer me to a person in CMS. He takes my complaint and sends Humana a complaint in my name. My question is why is this problem continuing since 2007? Why has Humana continued to refuse to actually fix what would seem an easy problem to fix? Is the part of their apparent reputation of not paying claims? But, most importantly, what else can I do? I know I have more than one question here but I am so frustrated! I have a small solo practice and I personally handle my own claims. I plan on quitting Humana but I want my money first. Sorry to run on. Thank you.
Answer
This is really outside of my expertise, since the regulations are different than in Louisiana than they are in my state.. You might contact the SHIP program in your State at 1-800-259-5201 and request to speak with a counselor who is an expert in Advantage plan appeals.You will get their nearest office, and they will know any special regulations for that State.
Around here we have a special number for most of the the plans so we can call a specific person in the plan. I do not know if that is true in all the
states, but they may have the same setup.
The Advantage plans have to give the client a packet of information containing what is referred to as a Certificate of coverage. When the person gets a denial they should follow the appeal process outlined in that packet, and if it is still denied go another step forward with the process. The plans rely on the patients not knowing how to properly appeal. Usually rather than keep getting time lost fighting appeals, they pay.
Sorry I could not be of much help.
John
Showing posts with label HMO problems. Show all posts
Showing posts with label HMO problems. Show all posts
Tuesday, March 16, 2010
Medicare/no fault auto insurance
Question
I fell and broke my wrist, I went to the hospital, then was referred to a Clinic, where I saw 2 different doctors, and they did surgery on my wrist. It was billed and paid through medicare. A few months later, I thought maybe my auto insurance would cover it, because it happened when I got caught up in my seat belt, and fell out of my car. I called my auto insurance, and they said they would cover it. They got ahold of medicare, and started the process with MSPRC. They called the clinic, and asked for a copy of their billing. They sent them a copy of the billing (not showing that medicare had already paid, or that they were billed). The insurance company (state farm) computer starting sending them checks. The checks totaled my entire entitlement, 10,000.00. MS{RC has now sent a lein letter to my insurance company, but there is no money left. State Farm, MSPRC, and Medicare have said the doctors office needs to return those checks, that they have already been paid in full by medicare. The total that State farm owes MSPRC is about 3200.00. The doctors office won't call MSPRC, they said they would not refund the money until they get it in writing from medicare, and they do not see that MSPRC and medicare and NOT one and the same. HELP!! Thanks
Answer
Hi Kathy
This is really a legal question and outside of my expertise.
BUT, maybe this might work for you. Call 1-800-Medicare..When answered you will be on the press the button section. ASAP say AGENT. You be transferred to the representative talk session. When that is answered request to speak to a claims specialist in reference to a claim that has been paid twice. Do not call on Monday or early in the morning or you will be on the phone all day. Have all the information you have ready when you call. The claims representative is the office that sends out those letters you are looking for.
I am not familiar with the legal actions that might be needed.
Hope this is some help.
John
I fell and broke my wrist, I went to the hospital, then was referred to a Clinic, where I saw 2 different doctors, and they did surgery on my wrist. It was billed and paid through medicare. A few months later, I thought maybe my auto insurance would cover it, because it happened when I got caught up in my seat belt, and fell out of my car. I called my auto insurance, and they said they would cover it. They got ahold of medicare, and started the process with MSPRC. They called the clinic, and asked for a copy of their billing. They sent them a copy of the billing (not showing that medicare had already paid, or that they were billed). The insurance company (state farm) computer starting sending them checks. The checks totaled my entire entitlement, 10,000.00. MS{RC has now sent a lein letter to my insurance company, but there is no money left. State Farm, MSPRC, and Medicare have said the doctors office needs to return those checks, that they have already been paid in full by medicare. The total that State farm owes MSPRC is about 3200.00. The doctors office won't call MSPRC, they said they would not refund the money until they get it in writing from medicare, and they do not see that MSPRC and medicare and NOT one and the same. HELP!! Thanks
Answer
Hi Kathy
This is really a legal question and outside of my expertise.
BUT, maybe this might work for you. Call 1-800-Medicare..When answered you will be on the press the button section. ASAP say AGENT. You be transferred to the representative talk session. When that is answered request to speak to a claims specialist in reference to a claim that has been paid twice. Do not call on Monday or early in the morning or you will be on the phone all day. Have all the information you have ready when you call. The claims representative is the office that sends out those letters you are looking for.
I am not familiar with the legal actions that might be needed.
Hope this is some help.
John
Posted by
zhengyun jin
Humana Gold Plus HMO
Question
QUESTION: I am a mental health provider in Louisiana with a provider contract with Humana and Corphealth, Humana's subsidiary covering mental health claims. I was already a provider with Humana when in 2007 I was made aware of their Medicare Advantage plan. I immediately contracted with Corphealth to work with Humana Gold Plus HMO since I was already working with many Medicare clients. Starting with the first claim I submitted in January of 2008, I have had every claim denied for payment by Humana with the denial being because I did not have a referral from the Primary Care Physician. I called Humana to inquire about the denials and I was told in Louisiana there is no requirement for the referral. We are the only state with this exclusion. (I recently found out this is because of Hurricane Katrina--LA residents were scattered across the country and could not get to their PCP's for referrals). So, I make a call when I received the denial and a claims rep states "you are right--you do not need a referral." The claim is resubmitted and paid about 2 weeks later. Again, I go through this with every claim! Now, in April, something changed. No, they did not fix their system to accommodate their own policy. They stopped fixing my claims and stopped paying. I have called provider relations, claim specialists for both companies. Yes, I am right, I do not need a referral. Please re-submit your claim but send it directly to this fax number and it will be taken care of. No, send it to this fax number. No payment received and further denials. It is now the end of August and I still have claims from April unpaid. So, I get tired of this runaround and contact the Insurance Commission office for Louisiana. They refer me to a person in CMS. He takes my complaint and sends Humana a complaint in my name. My question is why is this problem continuing since 2007? Why has Humana continued to refuse to actually fix what would seem an easy problem to fix? Is the part of their apparent reputation of not paying claims? But, most importantly, what else can I do? I know I have more than one question here but I am so frustrated! I have a small solo practice and I personally handle my own claims. I plan on quitting Humana but I want my money first. Sorry to run on. Thank you.
ANSWER: This is really outside of my expertise, since the regulations are different than in Louisiana than they are in my state.. You might contact the SHIP program in your State at 1-800-259-5201 and request to speak with a counselor who is an expert in Advantage plan appeals.You will get their nearest office, and they will know any special regulations for that State.
Around here we have a special number for most of the the plans so we can call a specific person in the plan. I do not know if that is true in all the
states, but they may have the same setup.
The Advantage plans have to give the client a packet of information containing what is referred to as a Certificate of coverage. When the person gets a denial they should follow the appeal process outlined in that packet, and if it is still denied go another step forward with the process. The plans rely on the patients not knowing how to properly appeal. Usually rather than keep getting time lost fighting appeals, they pay.
Sorry I could not be of much help.
John
---------- FOLLOW-UP ----------
QUESTION: That is okay. I have contact the SHIPP office in Louisiana and they referred me to a specialist in Medicare.
It sounds like you are saying that it is the responsibility of the consumer, my client, to ultimately get these claims paid? As the provider, I thought it was my responsibility.
Answer
Hi Leigh
As usual, there are no hard and fast lines as to who is responsible for claim payment.
The provider is responsible for knowing what is covered. which code to use. and informing the patient when something will not be covered, and submitting the claim to the right place.
The patient is responsible for appealing any claim denials.
They have to work together when there is a problem.In this case Humana is not following the proper regulations. That is where human failure comes in. Thy do not report fraud and abuse like they should. For providers it is found in the CMS Providers Manual, For the bennie it is on the back of the Summary Notice they get. When CMS gets enough complaints, they sanction the insurance plan like Humana.
We appreciate people like you who try hard to get it straightened out.
John
QUESTION: I am a mental health provider in Louisiana with a provider contract with Humana and Corphealth, Humana's subsidiary covering mental health claims. I was already a provider with Humana when in 2007 I was made aware of their Medicare Advantage plan. I immediately contracted with Corphealth to work with Humana Gold Plus HMO since I was already working with many Medicare clients. Starting with the first claim I submitted in January of 2008, I have had every claim denied for payment by Humana with the denial being because I did not have a referral from the Primary Care Physician. I called Humana to inquire about the denials and I was told in Louisiana there is no requirement for the referral. We are the only state with this exclusion. (I recently found out this is because of Hurricane Katrina--LA residents were scattered across the country and could not get to their PCP's for referrals). So, I make a call when I received the denial and a claims rep states "you are right--you do not need a referral." The claim is resubmitted and paid about 2 weeks later. Again, I go through this with every claim! Now, in April, something changed. No, they did not fix their system to accommodate their own policy. They stopped fixing my claims and stopped paying. I have called provider relations, claim specialists for both companies. Yes, I am right, I do not need a referral. Please re-submit your claim but send it directly to this fax number and it will be taken care of. No, send it to this fax number. No payment received and further denials. It is now the end of August and I still have claims from April unpaid. So, I get tired of this runaround and contact the Insurance Commission office for Louisiana. They refer me to a person in CMS. He takes my complaint and sends Humana a complaint in my name. My question is why is this problem continuing since 2007? Why has Humana continued to refuse to actually fix what would seem an easy problem to fix? Is the part of their apparent reputation of not paying claims? But, most importantly, what else can I do? I know I have more than one question here but I am so frustrated! I have a small solo practice and I personally handle my own claims. I plan on quitting Humana but I want my money first. Sorry to run on. Thank you.
ANSWER: This is really outside of my expertise, since the regulations are different than in Louisiana than they are in my state.. You might contact the SHIP program in your State at 1-800-259-5201 and request to speak with a counselor who is an expert in Advantage plan appeals.You will get their nearest office, and they will know any special regulations for that State.
Around here we have a special number for most of the the plans so we can call a specific person in the plan. I do not know if that is true in all the
states, but they may have the same setup.
The Advantage plans have to give the client a packet of information containing what is referred to as a Certificate of coverage. When the person gets a denial they should follow the appeal process outlined in that packet, and if it is still denied go another step forward with the process. The plans rely on the patients not knowing how to properly appeal. Usually rather than keep getting time lost fighting appeals, they pay.
Sorry I could not be of much help.
John
---------- FOLLOW-UP ----------
QUESTION: That is okay. I have contact the SHIPP office in Louisiana and they referred me to a specialist in Medicare.
It sounds like you are saying that it is the responsibility of the consumer, my client, to ultimately get these claims paid? As the provider, I thought it was my responsibility.
Answer
Hi Leigh
As usual, there are no hard and fast lines as to who is responsible for claim payment.
The provider is responsible for knowing what is covered. which code to use. and informing the patient when something will not be covered, and submitting the claim to the right place.
The patient is responsible for appealing any claim denials.
They have to work together when there is a problem.In this case Humana is not following the proper regulations. That is where human failure comes in. Thy do not report fraud and abuse like they should. For providers it is found in the CMS Providers Manual, For the bennie it is on the back of the Summary Notice they get. When CMS gets enough complaints, they sanction the insurance plan like Humana.
We appreciate people like you who try hard to get it straightened out.
John
Posted by
zhengyun jin
am i qualified
Question
I am only 19 years old but i have been out of work for 10 months. at the beginning of last year i was diagnosed with PCOS (poly-cystic ovarian syndrome) and i had an abnormal pap in April i was supposed to go back in Oct but i had no insurance and have not been able to find anywhere to help me... and my grandma died of ovarian cancer. So i was wondering if i would qualify for medicaid?
Answer
Hi Stephanie!
Medicaid is state specific meaning every state can have different guidelines.
Most states have an on line application. Do a search for Medicaid in (then list your state) to get to your website and see if they have an application. They also usually have simple questions that you can answer on line to whether or not you are eligible.
Sounds to me you are.
Good Luck!
Tricia
I am only 19 years old but i have been out of work for 10 months. at the beginning of last year i was diagnosed with PCOS (poly-cystic ovarian syndrome) and i had an abnormal pap in April i was supposed to go back in Oct but i had no insurance and have not been able to find anywhere to help me... and my grandma died of ovarian cancer. So i was wondering if i would qualify for medicaid?
Answer
Hi Stephanie!
Medicaid is state specific meaning every state can have different guidelines.
Most states have an on line application. Do a search for Medicaid in (then list your state) to get to your website and see if they have an application. They also usually have simple questions that you can answer on line to whether or not you are eligible.
Sounds to me you are.
Good Luck!
Tricia
Posted by
zhengyun jin
response to missing info
Question
I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
Answer
Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
Answer
Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
Posted by
zhengyun jin
response to missing info
Question
QUESTION: I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
ANSWER: Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
---------- FOLLOW-UP ----------
QUESTION: I don't understand the response. It sounded like an answer was imminent if you knew the missing info. Is there no statute or law that you could refer to in order to assist me? Calling 1-800-Medicare does not help me at all. I just need a statute or law to refer to. Is there something you could throw out at me? Please!!
Answer
Jim
I am not a lawyer and can not give you legal advice.
The path to a claims expert that I gave you is the regional office to CMS(MEDICARE) It is their office that enforces the regulations for this area. Providers and Medicare Advantage plans answers to them,
John
QUESTION: I had physical therapy (PT) services 2 years ago in Florida. I was referred properly. I have Medicare and a Medicare Advantage HMO plan (Preferred) which covered most, if not all, of these services. However, the PT never billed my insurance correctly and did not get paid. Do you know the florida statute/law (or is it federal?) which states that the PT cannot charge me over what my HMO plan would have paid had they billed the HMO in a competent manner? I need to be able to reference the law in a courtroom. Thanks!!
ANSWER: Hi Jim
Call 1-800-Medicare. When it opens up, you will be in the auto section so immediately say AGENT. You will be transferred to the customer representative section. When they answer tell them you want to speak to a claims expert. When you finally get that person, explain the situation and make your request for a letter.
Do not call on Monday or early in the morning, or you will be on the phone all day listening to music.
John
---------- FOLLOW-UP ----------
QUESTION: I don't understand the response. It sounded like an answer was imminent if you knew the missing info. Is there no statute or law that you could refer to in order to assist me? Calling 1-800-Medicare does not help me at all. I just need a statute or law to refer to. Is there something you could throw out at me? Please!!
Answer
Jim
I am not a lawyer and can not give you legal advice.
The path to a claims expert that I gave you is the regional office to CMS(MEDICARE) It is their office that enforces the regulations for this area. Providers and Medicare Advantage plans answers to them,
John
Posted by
zhengyun jin
Breast Reduction
Question
Hi! I was wondering why Medicare/Medicaid denied my request for breast reduction. I have severe back and neck pain, marks on my shoulders from the bra strap, and rash in between and under my breasts. Please help me out with this!!
Thanks
Answer
I have no idea. There is no authorization needed for this unless you are in a Medicare Advantage Program. It really has to do with how the physician presents it, If you are not in an HMO, Medicare does not require an authorization and will pay if it is medically necessary.
Hi! I was wondering why Medicare/Medicaid denied my request for breast reduction. I have severe back and neck pain, marks on my shoulders from the bra strap, and rash in between and under my breasts. Please help me out with this!!
Thanks
Answer
I have no idea. There is no authorization needed for this unless you are in a Medicare Advantage Program. It really has to do with how the physician presents it, If you are not in an HMO, Medicare does not require an authorization and will pay if it is medically necessary.
Posted by
zhengyun jin
Birthday rule
Question
Myself and my wife both work and her insurance is very bad so i want to put her on my plan and not use her plan at all. my work is telling me I must pay an extra fee because of the birthday rule. I know that it applies if we have children but we just got married and have no children. Is this legal for my work to do? I live in Ohio. It just seems silly that to put her on my insurance I must pay an extra $240 a month because I was born at the end of the year.
Answer
Hi Daniel!
The birthday rule is very common for many insurances......and if this is their rule then yes you have to pay more to add your wife.
The birthday rule has nothing to do with children, it is usually a spouse rule.
Good Luck!
Tricia
Myself and my wife both work and her insurance is very bad so i want to put her on my plan and not use her plan at all. my work is telling me I must pay an extra fee because of the birthday rule. I know that it applies if we have children but we just got married and have no children. Is this legal for my work to do? I live in Ohio. It just seems silly that to put her on my insurance I must pay an extra $240 a month because I was born at the end of the year.
Answer
Hi Daniel!
The birthday rule is very common for many insurances......and if this is their rule then yes you have to pay more to add your wife.
The birthday rule has nothing to do with children, it is usually a spouse rule.
Good Luck!
Tricia
Posted by
zhengyun jin
Medicare B special enrollment period
Question
"your spouse or family member stops working, or the date the Group Health Plan (GHP) or Large Group Health Plan (LGHP) coverage ends"
My question is what "coverage ends" means. My employer health insurance for couples has become very expensive. We can save a lot of money if my husband dis-enrolls and could take Part B without the penalty (he is 80 years old, I am 61 y/o).
My insurance is not ending. If he leaves my insurance voluntarily would this be considered "coverage ends". Many thanks.
Answer
Interesting question. Does your group have more than 20 employees? If so, did he ever sign up for Medicare Part A (free)? I would call Medicare so that you can explain to them your status. You probably will have to wait til the enrollment date to do this. Is Medicare the secondary coverage for him?
(I am going away on vacation so probably will not be able to get your response)
"your spouse or family member stops working, or the date the Group Health Plan (GHP) or Large Group Health Plan (LGHP) coverage ends"
My question is what "coverage ends" means. My employer health insurance for couples has become very expensive. We can save a lot of money if my husband dis-enrolls and could take Part B without the penalty (he is 80 years old, I am 61 y/o).
My insurance is not ending. If he leaves my insurance voluntarily would this be considered "coverage ends". Many thanks.
Answer
Interesting question. Does your group have more than 20 employees? If so, did he ever sign up for Medicare Part A (free)? I would call Medicare so that you can explain to them your status. You probably will have to wait til the enrollment date to do this. Is Medicare the secondary coverage for him?
(I am going away on vacation so probably will not be able to get your response)
Posted by
zhengyun jin
health care coverage for my daughter
Question
My daughter was being covered by my ex-husband on his insurance. He lost his job in December of 2008. He was suppose to get coverage for her. There is no communication with him at all and I can't find out if she is covered. I am now having to add my 20 year old son because he is going back to college. I want to add my daughter because I don't think she is covered. I do know that her father still does not have a job. My company does not want to allow me to add her. Is there anything that I can do?
Answer
Tough question. Is the coverage for your daughter part of a divorce settlement. How old is she? How can the father be covering the child if he is not working. You would need a note from the insurance company with the status of her coverage to show your employer. Not an easy thing..
My daughter was being covered by my ex-husband on his insurance. He lost his job in December of 2008. He was suppose to get coverage for her. There is no communication with him at all and I can't find out if she is covered. I am now having to add my 20 year old son because he is going back to college. I want to add my daughter because I don't think she is covered. I do know that her father still does not have a job. My company does not want to allow me to add her. Is there anything that I can do?
Answer
Tough question. Is the coverage for your daughter part of a divorce settlement. How old is she? How can the father be covering the child if he is not working. You would need a note from the insurance company with the status of her coverage to show your employer. Not an easy thing..
Posted by
zhengyun jin
Emergency room charge
Question
Hi, my son has been laid off for almost 2 years with no medical insurance but is getting unemployment which is ending soon - he went to the emergency room recently and just received a $250 bill - does he have to pay this or is there agencies that will take care of it or help out. We live in Dayton, OH - thank you for your help
Answer
Hi Doris!
Some hospitals have "charity care" or some name similar where patients without insurance coverage can qualify.
First call the hospital and ask if they have such a program. If not, contact your state and perhaps they can help.
Good Luck!
Tricia
Hi, my son has been laid off for almost 2 years with no medical insurance but is getting unemployment which is ending soon - he went to the emergency room recently and just received a $250 bill - does he have to pay this or is there agencies that will take care of it or help out. We live in Dayton, OH - thank you for your help
Answer
Hi Doris!
Some hospitals have "charity care" or some name similar where patients without insurance coverage can qualify.
First call the hospital and ask if they have such a program. If not, contact your state and perhaps they can help.
Good Luck!
Tricia
Posted by
zhengyun jin
Preexisting conditions
Question
Hi,
I'm 24 years old, just finished grad school, and am currently unemployed. Shortly before my graduate student health insurance ran out, I visited two urologists for a chronic problem (dysuria). Neither doctor ever arrived at a diagnosis. Here are my questions:
If I was never given a diagnosis, but was given a prescription as a diagnostic tool (which I will not refill, as it had no effect), is there any way around being described as having a pre-existing condition? If I begin to experience new symptoms that were not part of my condition before, can I go to the same urologist for those symptoms and not have it count as a pre-exsting condition?
Alternatively, will Medicaid cover pre-existing conditions? Will it be difficult for me to apply for Medicaid as a recent graduate?
Answer
Hi!
Pre-existing clauses are all different per insurance company.....some do not even allow them anymore. It would be impossible for me to tell you whether they would consider this as pre-existing but it does fall into that category, being treated a condition prior.
Medicaid is state specific so you would have to go on their website to see if they cover pre-existing. As far as applying, again Medicaid in each state has different guidelines. Most states have a quick application on their website where they will tell you right away if you may qualify or not.
Good Luck!
Tricia
Hi,
I'm 24 years old, just finished grad school, and am currently unemployed. Shortly before my graduate student health insurance ran out, I visited two urologists for a chronic problem (dysuria). Neither doctor ever arrived at a diagnosis. Here are my questions:
If I was never given a diagnosis, but was given a prescription as a diagnostic tool (which I will not refill, as it had no effect), is there any way around being described as having a pre-existing condition? If I begin to experience new symptoms that were not part of my condition before, can I go to the same urologist for those symptoms and not have it count as a pre-exsting condition?
Alternatively, will Medicaid cover pre-existing conditions? Will it be difficult for me to apply for Medicaid as a recent graduate?
Answer
Hi!
Pre-existing clauses are all different per insurance company.....some do not even allow them anymore. It would be impossible for me to tell you whether they would consider this as pre-existing but it does fall into that category, being treated a condition prior.
Medicaid is state specific so you would have to go on their website to see if they cover pre-existing. As far as applying, again Medicaid in each state has different guidelines. Most states have a quick application on their website where they will tell you right away if you may qualify or not.
Good Luck!
Tricia
Posted by
zhengyun jin
Medicare while your working
Question
I am 65 (last April), I am working full time. I am paying $45.oo a week out of my paycheck for company insurance. Company insurance doesn't cover all of my hospital bills. When I turned 65 last April did the part of Medicare that covers (not primary) hospital bills automatically start so that I can tell the hospital to bill Medicare for the part that my insurance did not cover.
Answer
Hi Karen
You need to do two things:
Call the Coordination of Benefits(COB) at 1-800-999-1118 and make sure that they have the right information in their computer regarding your coverage. They will probably send you a form to fill out with any new information not in their file.
Call 1-800-Medicare====As soon as the automated service answers, say AGENT====you will be transferred to the agent representative section====when they answers, tell that person that you want to speak with a claims specialist=== you will be transferred to the claims department==when they answer, inform them of the situation and after they explain the process for submitting claims they will send you the proper forms.
Do not call on Monday or early in the morning, or you will be on the phone all day.
Hope this helps.
John
I am 65 (last April), I am working full time. I am paying $45.oo a week out of my paycheck for company insurance. Company insurance doesn't cover all of my hospital bills. When I turned 65 last April did the part of Medicare that covers (not primary) hospital bills automatically start so that I can tell the hospital to bill Medicare for the part that my insurance did not cover.
Answer
Hi Karen
You need to do two things:
Call the Coordination of Benefits(COB) at 1-800-999-1118 and make sure that they have the right information in their computer regarding your coverage. They will probably send you a form to fill out with any new information not in their file.
Call 1-800-Medicare====As soon as the automated service answers, say AGENT====you will be transferred to the agent representative section====when they answers, tell that person that you want to speak with a claims specialist=== you will be transferred to the claims department==when they answer, inform them of the situation and after they explain the process for submitting claims they will send you the proper forms.
Do not call on Monday or early in the morning, or you will be on the phone all day.
Hope this helps.
John
Posted by
zhengyun jin
medicare coverage
Question
My mother (82) in otherwise good heath has just learned she has uterine cancer.My preference for her necessary surgery is Froedert Medical center rather than the general oncology surgeon(s) here in in Oshkosh. How much, where who etc. will her Medicare coverage pay for the doctor, anesthesiologist, hospital bills?
Answer
Hi Jean
Not enough information.
If she has original Medicare with a Medigap policy, there should be very little difference,If she has a Medicare Advantage plan like a HMO or a PPO, then: once again there should be little difference if the Advantage plan makes the referral and Froedert accepts the agreement.
However if Froedert is not a plan provider, and her plan will not make a referral, it amounts to a private contract, and she is responsible for the whole thing. especially if they have her sign an Advance Beneficiary Notice.
Hope everything is successful.
John
My mother (82) in otherwise good heath has just learned she has uterine cancer.My preference for her necessary surgery is Froedert Medical center rather than the general oncology surgeon(s) here in in Oshkosh. How much, where who etc. will her Medicare coverage pay for the doctor, anesthesiologist, hospital bills?
Answer
Hi Jean
Not enough information.
If she has original Medicare with a Medigap policy, there should be very little difference,If she has a Medicare Advantage plan like a HMO or a PPO, then: once again there should be little difference if the Advantage plan makes the referral and Froedert accepts the agreement.
However if Froedert is not a plan provider, and her plan will not make a referral, it amounts to a private contract, and she is responsible for the whole thing. especially if they have her sign an Advance Beneficiary Notice.
Hope everything is successful.
John
Posted by
zhengyun jin
poorly sized dentures
Question
My sister in law is on medicaid and just had all her teeth removed surgically in Fl(needed for health all rotten ) the dentist that handled this made the dentures wrong and they are way to large for her mouth and will not stay in even with 1/2 tube of super poly grip she has been back 4 times and they tell her to suck it up she is so discouraged and said that medicaid will only pay for one pair lifetime and she cant do anything very depressed now What do we do now where can we turn ? Please help.Thank You so much for the assistance and your time.
Answer
Does not sound like she has a lot of options regarding her coverage with Medicaid. However, there is an organization that might help. I have checked with a local support group and if they can locate the name of the group, I will let you know. You can email me directly for it: gail@teamgail.com.
Also Affordable Dentures will make a set for about $350 and they have a good reputation and have offices nationwide.
Another option may be to ask legal aid about malpractice.
Hope that helps.
UPDATE:
The name of the organization that may help is ModestNeeds.org
My sister in law is on medicaid and just had all her teeth removed surgically in Fl(needed for health all rotten ) the dentist that handled this made the dentures wrong and they are way to large for her mouth and will not stay in even with 1/2 tube of super poly grip she has been back 4 times and they tell her to suck it up she is so discouraged and said that medicaid will only pay for one pair lifetime and she cant do anything very depressed now What do we do now where can we turn ? Please help.Thank You so much for the assistance and your time.
Answer
Does not sound like she has a lot of options regarding her coverage with Medicaid. However, there is an organization that might help. I have checked with a local support group and if they can locate the name of the group, I will let you know. You can email me directly for it: gail@teamgail.com.
Also Affordable Dentures will make a set for about $350 and they have a good reputation and have offices nationwide.
Another option may be to ask legal aid about malpractice.
Hope that helps.
UPDATE:
The name of the organization that may help is ModestNeeds.org
Posted by
zhengyun jin
medicare
Question
I wish to cancel Medicare, Plans B, C, and D. I wish to only retain Plan A. How do I do this?
Answer
Hi Bruce
Part B: go to the local Social Security office and disenroll.
C and D, send them a letter dropping them and stop paying after that date.
Strongly disagree with your actions. If it is because of low income, a very serious mistake. You are probably eligible for for LIS and also the Medicare Savings program, and might even be able to keep what you have for less than $100 a month.
Go to benefits.com===enter your information and check the results. It will look over abot 400 programs and show you what you are eligible for.
Look at the MEDICARE AND YOU 2009 manual you can get at the SSA office. In the middle of the back cover is the local number for the SHIP program. Call them and ask to speak to one of the counselors and they will explan your options.
John
I wish to cancel Medicare, Plans B, C, and D. I wish to only retain Plan A. How do I do this?
Answer
Hi Bruce
Part B: go to the local Social Security office and disenroll.
C and D, send them a letter dropping them and stop paying after that date.
Strongly disagree with your actions. If it is because of low income, a very serious mistake. You are probably eligible for for LIS and also the Medicare Savings program, and might even be able to keep what you have for less than $100 a month.
Go to benefits.com===enter your information and check the results. It will look over abot 400 programs and show you what you are eligible for.
Look at the MEDICARE AND YOU 2009 manual you can get at the SSA office. In the middle of the back cover is the local number for the SHIP program. Call them and ask to speak to one of the counselors and they will explan your options.
John
Posted by
zhengyun jin
Secure Horizons Caseworker
Question
We recently experienced the dishonest and bullying treatment of a "hospital insurance caseworker" who rushed our parent who was being treated for a hematoma of the brain out of the hospital. First this person insisted that our parent was going home and when we insisted he was too weak to walk properly and disoriented, the caseworker finally found a nursing care facility so that our parent could receive some physical therapy. The caseworker told us that the insurance would not pay for our parent to stay in hospital and that no nursing facility would take him because he might try to get out of bed and walk on his own. My parent has secure horizons. We feel he is not being cared for medically as he should but is being pushed around by his insurance company HMO. What options are available for our parent. We read the hospital's patients bill of rights but they appear to be deferring to the caseworker! Please advise!
Answer
I would need to know more to give you a good answer. However, case workers can not make these decisions. You parent's medical doctor is the only one who can decide what setting is best for him/her. If your parent was put in the wrong setting and something happened his/her doctor would be responsible and could be subjecting himself to malpractice. Where is your parent now? Did they put him in a nursing home yet or is he/she still in the hospital? Please advise and I will respond further.
We recently experienced the dishonest and bullying treatment of a "hospital insurance caseworker" who rushed our parent who was being treated for a hematoma of the brain out of the hospital. First this person insisted that our parent was going home and when we insisted he was too weak to walk properly and disoriented, the caseworker finally found a nursing care facility so that our parent could receive some physical therapy. The caseworker told us that the insurance would not pay for our parent to stay in hospital and that no nursing facility would take him because he might try to get out of bed and walk on his own. My parent has secure horizons. We feel he is not being cared for medically as he should but is being pushed around by his insurance company HMO. What options are available for our parent. We read the hospital's patients bill of rights but they appear to be deferring to the caseworker! Please advise!
Answer
I would need to know more to give you a good answer. However, case workers can not make these decisions. You parent's medical doctor is the only one who can decide what setting is best for him/her. If your parent was put in the wrong setting and something happened his/her doctor would be responsible and could be subjecting himself to malpractice. Where is your parent now? Did they put him in a nursing home yet or is he/she still in the hospital? Please advise and I will respond further.
Posted by
zhengyun jin
MVAs and Medicare
Question
I practice medicine in Florida where there is mandatory PIP insurance for MVAs. I have occasion to treat some of these patients, many of which are already represented by an attorney by the time they call for an appointment. Many of these patients also sign a Letter of Protection allowing for deferment of payment for services until their legal matter is settled, however in most cases their PIP is exhausted by the time they see me. It is my understanding that we must first bill the patient's auto insurance even if they also have Medicare. Is that correct? If the PIP is exhausted are we then obligated by law to bill the patient's Medicare, or are we allowed to treat the patient under the LOP, especially if the patient has requested that we accept the LOP?
A problem that I have run in to on these Medicare-MVA cases has been that if I bill Medicare and check box 10 on the HCFA form identifying that this patient's condition is related to an auto accident, I receive a denial of payment from Medicare. Have you heard of this as well?
Answer
Hi Paul
Medicare is not the primary, the liability insurance is. Medicare will not pay until after the liability has been played out. Sometimes they will pay because of the hardship for the families, but then when the lability settlement arrives, the amount paid by Medicare must be returned to Medicare. To pay any unpaid bills, Medicare must have proof the the other Insurance action has been completed.
John
I practice medicine in Florida where there is mandatory PIP insurance for MVAs. I have occasion to treat some of these patients, many of which are already represented by an attorney by the time they call for an appointment. Many of these patients also sign a Letter of Protection allowing for deferment of payment for services until their legal matter is settled, however in most cases their PIP is exhausted by the time they see me. It is my understanding that we must first bill the patient's auto insurance even if they also have Medicare. Is that correct? If the PIP is exhausted are we then obligated by law to bill the patient's Medicare, or are we allowed to treat the patient under the LOP, especially if the patient has requested that we accept the LOP?
A problem that I have run in to on these Medicare-MVA cases has been that if I bill Medicare and check box 10 on the HCFA form identifying that this patient's condition is related to an auto accident, I receive a denial of payment from Medicare. Have you heard of this as well?
Answer
Hi Paul
Medicare is not the primary, the liability insurance is. Medicare will not pay until after the liability has been played out. Sometimes they will pay because of the hardship for the families, but then when the lability settlement arrives, the amount paid by Medicare must be returned to Medicare. To pay any unpaid bills, Medicare must have proof the the other Insurance action has been completed.
John
Posted by
zhengyun jin
surgery coverage under medicare
Question
Is it true that a patient over the age of 80 would not be covered for hip replacement surgery under medicare (because of age)?
Answer
Hi Bob
That is an easy excuse for not covering something. If the doctor says it is medically necessary and assigns a claim code that says so, it is covered.
there is growing concern that because of the long recovery period for older persons having hip replacement, that the process might be causing more harm to the body condition as a whole, than they are getting from the replacement.( I am in my eighties),
John
Is it true that a patient over the age of 80 would not be covered for hip replacement surgery under medicare (because of age)?
Answer
Hi Bob
That is an easy excuse for not covering something. If the doctor says it is medically necessary and assigns a claim code that says so, it is covered.
there is growing concern that because of the long recovery period for older persons having hip replacement, that the process might be causing more harm to the body condition as a whole, than they are getting from the replacement.( I am in my eighties),
John
Posted by
zhengyun jin
Denied preauthorized claim
Question
My eployer changed health plans when I was 6 mos pregnant and my doctor and hospital were not covered on the new plan. I talked to the insurance company and they told me to file a transition of care form for each provider and if approved they would cover at full benefit so I would not have to change dr or hospital that late in the game. I did. I have the originals I filled out and the fax confirmation that they received all pages. I called to check the status before going to the hospital and got the authorization number. I gave copies of all the forms and authorization to the hospital and Dr's office. Humana HMO still denied all the claims, and now I have collectors coming after me and I am being sued by the collection agency of the Dr. What can I do?
Answer
Hi Kerri!
If you have a written authorization then all you need to do is to send any bill to them with a copy of this proving that all providers were authorized for care. You might also call them and see if they will allow you to fax them the written authorization.
Usually they will stand behind their authorizations so it may just be an error on their part.
Good Luck!
Tricia
My eployer changed health plans when I was 6 mos pregnant and my doctor and hospital were not covered on the new plan. I talked to the insurance company and they told me to file a transition of care form for each provider and if approved they would cover at full benefit so I would not have to change dr or hospital that late in the game. I did. I have the originals I filled out and the fax confirmation that they received all pages. I called to check the status before going to the hospital and got the authorization number. I gave copies of all the forms and authorization to the hospital and Dr's office. Humana HMO still denied all the claims, and now I have collectors coming after me and I am being sued by the collection agency of the Dr. What can I do?
Answer
Hi Kerri!
If you have a written authorization then all you need to do is to send any bill to them with a copy of this proving that all providers were authorized for care. You might also call them and see if they will allow you to fax them the written authorization.
Usually they will stand behind their authorizations so it may just be an error on their part.
Good Luck!
Tricia
Posted by
zhengyun jin
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