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Monday, 30 July 2012

The Medicare Blues

By Kathleen Noble of The Dassler Diaries

It's finally over. My year-long battle over a $364 laboratory bill that had been denied by Medicare (and therefore not covered either by my supplemental plan) is over - and I lost. The bill to Lab Corp got paid - but by me, not Medicare.

I had one of the same two tests again this January - six months later - and Medicare paid the bill without blinking an eye. I have a chronic Vitamin D deficiency (yeah, right, here in sunny Arizona) and my doctor tested me to see if it was improving because of a supplement I was taking.

My purpose in writing about this admittedly boring topic is to help you avoid going through what I went through. Even if you are not on Medicare, my story may help you deal with denials from Medicaid or your own insurance company.

If you choose not to read any further, here are the two things I learned from losing this battle:

First, ALWAYS ask your doctor for a printout of your medical record from an appointment before you leave the office. Keep the records in a place where you can easily find them. Your doctor's office may have a system of storing your medical records online, if you need them from past appointments. Find out if they do or ask them for past copies, if needed.

Second, if services are denied by your insurance company or Medicare, file an appeal as soon as possible. The directions are simple and are sent along with the letter explaining why the charges were denied.

INCLUDE A COPY OF YOUR MEDICAL RECORD FROM THE DATE OF SERVICE AND A LETTER OF EXPLANATION FROM YOU. An upper level manager from Medicare actually told me that nearly all lab tests are denied when first submitted to them if they are labeled as "routine tests."

You must file an appeal within 120 days from the date of the denial letter, so do it soon.

I thought that an appeal was the last and final route to take in reversing my Medicare denial. I spent many hours leaving messages for my doctor or the clinic manager, talking to them, writing them notes, calling Medicare and Lab Corp, collecting and mailing paperwork, etc. and was told by both a Medicare employee and my doctor that the problem was a simple "coding issue."

I thought that my doctor could simply resubmit her bill with the correct code and - bingo! - problem solved! This was not the case.

I eventually filed an appeal but it was past the 120-day limit and was denied. No amount of explanation would make Medicare reverse its decision on my appeal.

I was not notified at all of the second denial until someone called me today – more than a year from the date of service - to explain the details and tell me what to do if this happens again.

I could have filed a third appeal if today's call had come earlier but the 60-day limit for the next appeal had already come and gone by the time I got the call.

I kept telling myself that it was not the money but the principle of the thing. I needed these tests, my doctor prescribed them and Medicare wouldn't pay them.

It turned out that Lab Corp did not have a written explanation from my doctor as to why the tests needed to be done and that she had used a medical code that was not the correct one.

My doctor told me that she used the same code that she always had used! I really like my doctor and have no intention of switching to someone new. It is too late now to get a refund from Lab Corp or Medicare for the $364 I spent.

And yes, it's not about the money, but my husband and I are attending a family reunion in the northwest next week and that refund check would really have come in handy!

[INVITATION: All elders, 50 and older, are welcome to submit stories for this blog. They can be fiction, non-fiction, poetry, memoir, etc. Please read instructions for submitting.]

Posted by Ronni Bennett at 05:30 AM | Permalink | Email this post


While I live in Israel (where EVERY citizen is insured), and enjoy sane health insurance coverage and care, your story is decidedly NOT boring. Thank you for writing about the maddening costly errors, slips, and rulings that robbed your time, money, and serenity. Good for you fighting the good fight, and sharing here so that others might benefit from your experiences, warnings, and lessons.

Your story brought back memories of dealing with employee tax benefits many years ago when we owned a small business. The issue went on and on until I found one sympathetic person in the tax office that took the time to look at my side of the issue and that of our employee.
Lesson: Dealing with big government is not a task for the faint of heart.
Michigan Grandma

I am sorry you lost,Kathleen, but I am proud of you for fighting the good fight.

You'll know better the next time and,thanks to you,so will we.

I have had bad experiences with Lab Corps. I don't trust their results.

I am sorry,too,that you lost.

As a retired doctor (Internal Medicine), I will try to address your concerns.

First, if the tests were done routinely, which means they were not medically necessary, Medicare will not pay for them. Did your doctor explain to you what they were done for?

Secondly, if this is mainly a coding issue, that usually means Medicare is being overbilled. Laboratories are notorious for billing excessively for tests that are now done by machines. A chemistry profile, for instance, encompasses 12 or 15 tests. Those can be bundled together as one bill, or if the laboratory wants to make more money, it can bill those separately - resulting in a much larger bill. That is a no-no with Medicare and with most private insurance companies.

Regardless of whether this was an issue of medical necessity or incorrect coding, your doctor should have taken the lead to explain to you what he did, if those tests were medically necessary, and why Medicare refused to pay. I always took the time to explain to my patients any serious billing problems they had, notwithstanding that I had excellent personnel who could do the same job. (The doctor makes the coding sent to Medicare commensurate with what he did for the patient.)

In this particular instance, "coding" is an alien issue for most patients, and I am not sure I would just tell you I used the same coding I did last time. That entails explaining in greater detail what Medicare was talking about concerning that coding. I suspect this was overbilling.

Since you were not given any satisfactory explanation by the doctor and his office help to explain Medicare's refusal to say, I can understand your bitterness. The lesson here is your doctor, no matter how much you like him, ought to be ultimately responsible for actions he initiated, and to explain any consequences resulting from such actions (in this case ordering those tests that Medicare refused to pay.)

Praising whatever fate made that short blonde Canadian so attractive to a girl who loved tall, dark men, because it means I've lived the last 41 years in Canada where excellent health care is universally available and there are no medical bills to pay. I went to the cardiac clinic at the nearby hospital for an echocardiogram and a 24-hour Holter moniter and (darn) it cost $3.75 to park. I'd hate to be old in the USA.

With all due respect, I'm not sure I agree with deb's assessment of the health system in Canada.

In 2009, when the new president of the Canadian Medical Association, Dr. Anne Doig, took office, she said that the system there was "broken" and "imploding." It's also getting more and more expensive, which means higher taxes on citizens to keep it afloat.

Sally Pipes, a Canadian who immigrated here and has become the CEO of Pacific Research Institute, has written books and articles harshly critical of the socialized system there. She lost her mother in that system because of the delay that it took her doctor to schedule a common procedure that would take a day or two here in the U.S.

Here is what we know about the health system there: a critical shortage of primary care doctors; long waiting periods to see doctors, particularly specialists, sometimes as long as 6 months; sparse high-tech diagnostic equipment like CT scans and MRIs resulting again in long waits and delayed diagnosis and treatment; and antiquated hospital facilities.

It's no wonder thousands of Canadians come to the U.S. yearly for treatment because of those problems. Hundreds of Canadian doctors also immigrate here because, like the United Kingdom which has a similar socialized system, there is no room for them to practice under conditions that can only be found here. It's not surprising that the U.S. has become a magnet for doctors around the world to come here for training and to practice.

In Canada, there is a growing movement to at least privatize part of its system to allow those who want to enroll in a private insurance market similar to what Great Britain did. That ought to be an escape valve for patients who don't want to go through that bureaucratic morass that is the country's broken health system.

If interested, deb can buy a number of books that Sally Pipes had written about Canada's health system. Sally is highly respected as one of the best health care experts here and in Canada.

Socialized systems, in short, are OK for those who are healthy. But if you are sick needing urgent or emergent medical attention, or when you get old and develop all those problems associated with aging, nothing beats the system here in the good, old U.S.A.

I am coming to the party late but, gee, "with all due respect" to R., G. Lacsamana that is an outrageous distortion of the truth about Canadian healthcare. I am a Canadian in a poorer province and if the healthcare system in Canada is broken it would be here where I live. Yes there are problems but nothing like what R., G. describes. deb's description of her own experience is true for many of us. I am over 60, I have had health issues, and I have had good care at no cost. Wait times can be onerous but not dangerous, doctors are indeed in short supply particularly in rural areas (and I hear that the USA faces the same situation in some parts), and mistakes do get made here as elsewhere in the world. The so-called growing movement to privatize is largely spearheaded by doctors looking for greater profits, the vast majority of Canadian citizens still prefer the current system with all its problems. Politicians challenge public healthcare at their risk, it is generally considered a "sacred cow" on the Canadian political scene. We love it.

And also, I note that R., G. mistakenly refers to Kathleen's doctor as "he" throughout his or her first comment; a proper reading of Kathleen's account would have revealed her doctor to be a "she".

I’m from the South. With all due respect here interprets to what I think of the appeal system of Medicare. Yes, Medicare did finally see the test was medically necessary. Yes, Medicare did refund said amount ~ to the doctor we had already paid. Then it was the old check is in the mail from his office manager. Thank God the service was performed by a specialist we never have to use again and not by our primary care provider formerly known as our family doctor.

In reply to Annie, those are facts you cannot twist and which are shared by many others familiar with the Canadian health system.

Would the president of the Canadian Medical Association lie when saying that system is "broken" and "imploding?"
Would Sally Pipes, a recognized expert of that system, lie in her numerous books that dissect the problems of that system? And how can you refute all the problems I outlined in my previous post?

As for the private insurance market, that came about from a lawsuit filed by a patient who could no longer wait to have a surgical procedure for a hip problem. He wanted to seek a private doctor but was denied. But the Canadian Supreme Court, in 2005, ruled in his favor and against Quebec's prohibition of private insurance. That was never, NEVER meant to make doctors wealthy.

As for funding, this comes from general revenues through corporate and personal taxes, with block grants from Ottawa to each of the 13 provinces and the three territories. But since these block grants cover only 16% of health expenses, the remainder comes from additional taxes levied by the provinces. These have been getting higher and higher for the past several years.

Yes, it's true there is universal access, but the larger question is whether this is enough to make up for all the system's glaring deficiencies. Which explains why Canadians still come to the U.S. to seek treatment they cannot get there on time, or because it's not available there.

All this should remind us that once more that there is no such thing as a FREE LUNCH.
You get what you pay for, and that is a broken system that
is getting more and more expensive.

(I am a red-blooded male, and that gender confusion Annie talks about is a minor oversight that has no bearing on what we are discussing about your health system in Canada.)

Interesting how hot this socialized medicine debate can be. After living for years in fear of a medical crisis obliterating what little savings we have, I now have insurance through my husband's job, and the long term affect of not having good lifelong medical care has left me with dehibilitating bone loss. I am in the prime of my earning career and am sidelined. Maybe Canadians don't have a perfect system, and yes losing out $300 is crazy/stupid over an administrative burp. But living on the health edge as so many of my generation has done will leave our nation poorer because of it. It's time we take physical care of the bread earners in our country or the U.S. will be hurting worse than we are in the future. Been there, done that.

And thank you for the article giving us some tips on how to address a frustrating issue.

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