Re: Billing practices

[Guest guest]

Doctors who accept medicare can not bill for services that medicare does not

cover. They can bill for the 20% remaining after medicare has paid if you do

not have a supplement. The doctor's office can file an appeal with medicare for

a service not paid, but the patient is NOT involved in any of that.

If your doctor insists on a drug test and you are under medicare or medicaid

which will not cover that service, maybe you either need to remind the doctor or

tell their billing that you were told by your insurance that since it not a

recongized service the patient is not responsible for the cost. They will know

that.

If the doctor wants you to take a drug test, trying to avoid it because you

think you might be billed could look like you are guilty of something. the

doctor could drop you. I would just take the test.

Gentle hugs, Tami

[Guest guest]

On this subject, is anyone out there on disability and how bad is list of docs

that you are limited to? i found atty to get me disability for my knee surgery

but I am scared. I cannot have good surgeon because of list they limit you

coverage, also how can i get list so i can begin researching docs available?

HELP am scared of having quack operate on me !

JK@...

[Guest guest]

,

I am on disability and I have had my gall bladder taken out by a really good

Dr...He did a great job. I'm seeing a really excellent gastro doctor,

rheumatologist and pain specialist. I have medicare. Many doctors take

medicare. If you have medicaid only I think that may what your talking about.

But I know others who have medicaid and have good doctors also. You just have to

do some research on the doctors when looking into having any surgery. Don't be

scared. Find out what kind of insurance you are going to get,

medicare/medicaid(ssa) or medicaid alone(ssi). If its medicaid alone(ssi) than

the office in your area (the local medicaid office) should be able to send you a

list of doctors in your area. Which they probably will do when you get accepted.

My friend had medicaid when he got sick and was on disability and saw some of

the best specialist doctors at the University of Chicago. So, don't panic, ok?

Good luck with your knee.

Blessings,

Cloverskies

> wrote:

> On this subject, is anyone out there on disability and how bad is list of docs

that you are limited to? i found atty to get me disability for my knee surgery

but I am scared. I cannot have good surgeon because of list they limit you

coverage, also how can i get list so i can begin researching docs available?

> HELP am scared of having quack operate on me !

[Guest guest]

> wrote:

> On this subject, is anyone out there on disability and how bad is list of docs

that you are limited to? i found atty to get me disability for my knee surgery

but I am scared. I cannot have good surgeon because of list they limit you

coverage, also how can i get list so i can begin researching docs available?

> HELP am scared of having quack operate on me !

Hi ,

I had a difficult time finding a Primary Care Physician (look for a clinic in

your area), but then it was easy to get referrals to Great Specialists! That's

the key. Referrals. I guess they have to take you when your referred. I have had

the best of the best including Gastro, Rheumatology,and Surgeons of all types,

etc. I live near Denver, Co and by association with theses specialists, access

to the best hospitals. I am also on Medicaid, which no one wants to take, trust

me! They have to take it once they see you on the basis of Medicare.

Look up Primary Care Physicians or Clinics that accept Medicare and/or Medicaid

in your area. You might have to get on a waiting list for an appointment, but

it's worth the wait. Then tell the Doctor or P.A. what referrals you need. In

the meantime, research the best knee surgeons out there who will take Medicare.

There should be many. Tell your Primary whom you wish to be referred to

(remember, the Doctor is employed by you, no matter how you are paying for it!).

Give him/her the name, address, phone number, etc so they don't make an error.

That's what I do so I go to the best!

Good Luck with your surgery!

Debie

[Guest guest]

A wrote:

> Doctors who accept medicare cannot bill for services that medicare does not

cover. They can bill for the 20% remaining after medicare has paid if you do

not have a supplement. The doctor's office can file an appeal with medicare for

a service not paid, but the patient is NOT involved in any of that.

>

> If your doctor insists on a drug test and you are under medicare or medicaid

which will not cover that service, maybe you either need to remind the doctor or

tell their billing that you were told by your insurance that since it not a

recognized service the patient is not responsible for the cost. They will know

that.

>

> If the doctor wants you to take a drug test, trying to avoid it because you

think you might be billed could look like you are guilty of something. the

doctor could drop you. I would just take the test.

>

> Gentle hugs, Tami

Tami,

You do have the right to be part of this process and I have called Medicare

myself, looked up the CPT code for Botox for medical skeletal spasm as there is

a " other code category "

and I was able to get it paid for with the justification. Don't ever think you

cannot be part of the process, there is a case manager that you can speak to

anytime and I have gotten my bills paid for many a time that some insurance and

billing reps did not know about.

It is your right to appeal and that is why they put the codes and they even

state to provide them with additional information about your condition and where

to mail or call. The patient IS involved in that as you are the person that can

provide the information that could get the justification. The Doctor cannot

bill you for a charge if they have coordinated with an insurance company the pro

rated rate and they CANNOT charge you beyond that . Your explanation of

benefits explains this, the co-payment and deductible is understood as part of

the charge, the Doctors cannot charge you you 200.00 for a visit if they agreed

on a rate of 150.00 and also ask you to pay the difference. Software programs

will show the higher amount and sometimes Doctors will get you to sign a form

that states that you will be responsible for the difference in rates. This is

not allowed in a negotiated rate.

This is what I was speaking about Not the co payment or deductible and the

patient is allowed any time to appeal but there is time period, this is

especially true of medications which require certain forms.

http://www.medicare.gov/navigation/medicare-basics/understanding-claims/medicare\

-appeals-and-grievances

Always be an advocate for yourself and know the patient bill of rights and pain

patient bill of rights.http://www.nlm.nih.gov/medlineplus/patientrights.html

talks about this and other issues as second opinions. Here is the federal law

for pain patients : www.painpolicy.wisc.edu/domestic/states/HI/billofrights.pdf

You bring up good points but my Medicare paid for the drug tests monthly. I

always call Medicare beforehand EVEN if the office says Medicare will pay and

verify they are paying for the service (such as outpatient ambulatory surgery)

and you can even ask for a copy of the approval from Medicare they called.

This prevents bills placed that on you to be responsible for. Also, the lab

techs where I go to get my thyroid tests always state that Medicare only pays

for three thyroid tests a year. Well, my thyroid tests were way off and needed

more monitoring so I called Medicare and they said, No, that is not what the

supplement states, all my doctor had to do was provide additional justification

and I told the lab tech they should add this to what they tell the patients as

they are wrong and people might not take tests they need, She said it was a

policy of their labs.

This also happens with physical therapy visits they are saying you can only have

1800.00 or something a year and I called Medicare, same thing No, this is not

what supplement says, just get Doctor to provide additional justification.

I have had all my appeals approved and all my tests paid for. This happened

because I called. I also got justification for my Provigel and other medications

and this would not happen unless I called and was advocate for myself. I

encourage everyone to do the same. Bennie

[Guest guest]

If you are going for social security disability it will take time for you to

become eligible for medicare. I am not sure how medicaid works under SSI.

If you are eligible for welfare, it usually takes about 30 days to get

medicaid/medical assistance.

In terms of doctors I can tell you from experience (my own and others) that most

doctors will take medicare. The amount of doctors taking medicaid is limited.

You can get a list of doctors from the insurance or by contacting your local

county medical association.

Did you apply for SSA disability? If so did you get turned down the first time

and are you in appeal?

Hope this helps some in answering yoru question. Hugs, Tami

>

> On this subject, is anyone out there on disability and how bad is list of docs

that you are limited to? i found atty to get me disability for my knee surgery

but I am scared. I cannot have good surgeon because of list they limit you

coverage, also how can i get list so i can begin researching docs available?

> HELP am scared of having quack operate on me !

>

>

> JK@...

>

[Guest guest]

My wife's great-aunt has private insurance with a $1500 deductible.

An office visit with her Endocrinologist costs about $125 cash and the

allowable amount is about $50 ($75 write-off). The insurance only subtracts

$50 from the deductible per visit because the contract says she can only be

billed the allowable amount. They bill her the full $125, which effectively

doubles her deductible. They do the same thing with the blood tests that

they run.

She had $4500 unpaid that I got reduced to $700 after fraudulent billing

was corrected. Unfortunately, I was only able to go back two years, but

they've been doing this for only God knows how long.

What's really messed up is that they keep doing it! Every time!

One time, they double billed her for the same appointment. The insurance

paid one visit and said the second was the offices responsibility. Can you

guess who they charged?

To make matters worse, when I had them fix it, they still tried to charge

her a copay for the second, non-existent visit. It was eventually fixed,

but the whole situation was insane.

If I hadn't have looked through every medical bill when I did her taxes,

their " mistake " (they're know for A LOT of billing " mistakes " ) might never

have been caught.

The moral of the story is to be careful, read those EOBs before you pay a

dime, and understand your coverage and the billing practices of the

providers and your insurer.

As far as urine drug tests, I think reminding your doctor that they're

expensive (lab confirmed ones cost 100s of dollars) and you can't afford

frequent testing and ask them to keep them infrequently, it is usually

okay. The random testing makes frequent testing unnecessary.

Either insurance needs to start covering these (I doubt it aoncs they're

not medically necessary), or doctors need to trust their patients and not

test so often. Yeah, I know, not going to happen, but I can dream, right?

Steve M in PA, age 22

Married with 3 year old daughter

[Guest guest]

,

They keep doing it as it is hooked up to their software program and cpt codes so

the person puts in the cpt code for a service for a region and it doesn't allow

for contract and negotiated rates.

I audited Doctors and one doctor did this unintentionally but they were charging

for extended visits when the time and hands on was just follow up charge.

I also was only able to go back three years that is why I tell people to check ,

check. I am glad that she has you as I used to get so angry that elderly people

who are proud and pay their bills, pay bills they are not really responsible for

and audits should be done by office managers ever six months to check up on

things. The confusion is the software program goes ahead and puts a charged rate

which is high and is misleading and then subtract out or " adjusts " and this way

they can write off these amounts (legally) but it is a system that tends to

allow improper billing and charging and patients and family do need to check and

not depend on " the billing office " as that is between them and the insurance, NO

its my insurance premium I am paying : )

In my auditing over a two week period, I found over three million in a ten per

cent charts of Doctors patients then with what I found we had to do an expanded

audit and this was an accreditation item and Doctor had to pay back and they got

rid of the software program that did their invoices and the doctor before them

sold them : )

You could be a great medical researcher and patient advocate.

Bennie

[Guest guest]

" You could be a great medical researcher and patient advocate "

Thanks, I try.

Hi Bennnie

What pissed me off was that they tried to over bill the same line item

even after I brought it to their attention.

Personally, I believe that NO ONE should pay their medical bills

without having someone go over it unless they REALLY understand.

My wife had Medicaid growing up and her PCP charged her $30 co-pays at

EVERY appointment. When her mom questioned it, they said she couldn't

be seen without paying the copay. The billing department should have

flagged this. Her primary insurance had a $30 pay, her secondary

(Medicaid) had no co-pay. She was sick often and they overcharged

THOUSANDS of dollars over at least a decade. When Medicaid was

mentioned, they should have passed it along if they didn't understand.

She never should have paid, but they never should have lied to her to

get the money. I eventually (age 16) caught it, but they REFUSED to

refund a dime to her. I should have reported them, but I didn't think

of it until years later.

Everyone out there, BE CAREFUL. If you get a bill, compare it to your

EOBs. MANY doctors over-bill. If you don't understand, find someone

who does. NEVER blindly pay anything. This is especially important if

you have multiple insurance carriers, Medicare, and/or Medicaid

(Medical Assistance).

If anyone ever needs help understanding a bill, I'd be happy to help.

My off-group email is SteveMatrese@...

Please be sure to blackout (or remove another way) any personal

information (such as last name, address, SSN, DOB, Insurance ID

number) before sending it.

Steve M in PA

,

They keep doing it as it is hooked up to their software program and

cpt codes so the person puts in the cpt code for a service for a

region and it doesn't allow for contract and negotiated rates.

I audited Doctors and one doctor did this unintentionally but they

were charging for extended visits when the time and hands on was just

follow up charge.

[Guest guest]

> " You could be a great medical researcher and patient advocate "

> Thanks, I try.

,

This was my job for years, auditing these practices, and I found the employees

of the Doctors office to be the worse. They do not understand CPT codes which

qualify what is paid by the insurance and is listed in categories of the body.

For each CPT code like an office visit for back pain, the code must match what

is done and what is charged. If the Doctor charges and extended visit, the notes

must reflect the Doctor did an exam and vital signs. You do not know how many

charts I audited that Doctors just charges extended visits without

justification.

The hospital uses DRG (disease related groups) and for each thing you are

diagnosed, they allow a number of days and things they pay for.

In each of these there ar an OTHER category that they can use if what they are

diagnosing is not in the CPT book or software and employees have to know how to

use this.

This is also listing online http://www.fieldhealth.com/Hcfa_CPT_Code_List

talks about Current Procedural Terminology if you want to see.

I was referred to see this thyroid specialist who had branch offices everywhere

and talk shows. I NEVER saw her but I saw multiple Physicians Assistants that

all said different things ! They were charging me a rate that I was being seen

by the specialist. The specialist is supposed to see me first and then turn me

over to the Physicians Assistants, recommending a treatment plan.

This specialist was re-known for doing this and the school nurse I worked with

was done this way and the specialist nurse became my primary care nurse and she

told me that the Doctor never saw patients and was just an assembly line.

Well, I reported her and everyone's insurance company has a contact to report

the Doctor or you can report them to the State Licenser Board or State Insurance

Board. Some of my hospital bills I was charged for things I never received and

had them credited. I also had a " surgical assistant " charge that my Doctor had

without letting me know and I asked the hospital why the hospital surgical

assistants were not used and this was not ethical as the surgical cost I was

charged included a hospital surgical team and this was a simple kidney cyst

removal.

Doctors will have you sign forms that state that you will pay charges not

covered by your insurance. I never sign these or put " I do not agree with this "

as the Doctor has advertised that he accepts my inurances charges. This is

illegal and unethical. You need to know the memorandum that your Doctor and

Insurance company has.

I agree with and I always call the Quality Assurance Officer at the

hospital as they have to file a report and research it or it is a mark against

their accreditation.

The more you become involved in this process, the more empowered you are. As I

said, I have appealed and gotten my services paid with Medicare. It is worth

following up and understand your explanation of benefits and call the insurance

case manager, they are getting paid to help. I enjoy getting things paid for

people deserve. Bennie