This is my 2nd level appeal on the preventative screening abdominal aortic aneurysm exam I had back in Novermber. Imaging lab miscoded the claim and I got a bill for the 20% co-pay. (Since it’s “preventative screening” there’s no co-pay.)
I was initially disappointed at the “Unfavorable”, but on reading the 6 page letter I found that “Medicare agreed that we are responsible for the denied payment” (i.e, the 20% co-pay} But then said “Medicare declines to make any additional payment.”
On further research I learned that Medicare doesn’t allow medical providers to correct billing codes once the claim is paid. That’s why the ruling is “Unfavorable”. So the imaging lab has to eat the 20% co-pay. And they can’t come after me for it. But the 6 page letter wasn’t clear on that point.
I can’t imagine the average senior citizen successfully going through the appeals process without some kind of knowledgeable help.
I went through the same thing. Had the service provider rebill with the correct code, after I told them what the correct code was. Medicare didn’t pay. The woman on the Medicare help line said something like “it was paid under “assumed billing”” or some such thing. Medicare said I could not appeal until I received the printed explanation of benifits form in the mail. I never received the printed form. I ended up paying the $200, or whatever it was, to the service provider.
Docs and labs have patients sign an agreement to pay for anything not covered by insurance. If Medicare chooses not to pay, why does the imaging lab have to eat it?
I have a theory. If Medicare refuses to pay entirely, they will accept corrected billing. I went through that with my doc’s office for my first two annual checkups on Medicare. The doc billed with the wrong code, so payment was refused entirely. I told the doc what code to use. They rebilled. Then Medicare paid.
The problem with the aortic thing is Medicare paid something, not fully, or correctly, but something, so Medicare’s position is “case closed”.
I ran into that sort of thinking when trying to collect on returned checks. If you take a partial payment, you give up your right to go after the perp legally for the rest.
In general, what this story illustrates is that virtually all insurance providers and markets operate in a way that isn’t optimized for ACCURACY and FAIRNESS. Instead, they are optimized in a way that reflects an imbalance of information between insurers, providers and customers and uses that imbalance to devise rules that freeze ill-gotten benefits in the pockets of those with leverage.
In this case, the fact that bills flowed electronically between actors in the process and were essentially “cashed” by the lab accepting 80% of the payment before anyone could realize another 20% should have been paid led Medicare to stick the lab with 20% of the cost Medicare SHOULD have paid because “hey, by accepting the 80%, you are stating the billing is correct and the claim processing is complete.”
When a trillion dollar market is optimized for leveraging information asymetry for profit instead of accuracy and fairness, expect market abuses and incredible inefficiency.
Car insurance works the same way. I was involved in an accident that totaled my car in 1999. Not knowing how long it would take the insurance company of the at-fault driver to settle and needing a car immediately, MY insurance company “helpfully” volunteered to pay me SOME amount for my totaled car while they then filed a claim with the at-fault driver’s firm. I got money within a week for probably about 70% of what my totaled car was worth but hey, I can get the other 30% from the other company, right?
WRONG. When my insurance filed the claim with the at-fault driver’s insurance, they immediately paid the claim… for exactly the 70% my company had volunteered to pay me. When I asked my firm where the rest of the money was, they said, well, by accepting OUR check, you essentially accepted THAT as your settlement, regardless of WHO actually wound up paying it.
This is another example of how people without much liquidity pay extra “taxes” in the form of opportunistic business practices that work against those that cannot wait for fair / accurate settlements.
A lot of our discussions here are basically about how 1990’s “neo-liberal” pro-free-market reform has been destroyed by the inability of corporations to abide by regulations, instead always grabbing for maximum short term profits.
Or, in other words, the USA has the most efficient oligarchical structure in the world, to the detriment of almost all.
I think that’s what the 6 page letter I received is designed to do. Make you pay money you don’t owe.
On the first page they write:
“The appeal decision is UNFAVORABLE. Our decision is that Medicare will make no additional payment. More information is provided on the additional {five} pages.”
No where in the additional five pages does it say that “the beneficiary is not required to make any additional payment on this claim.” You actually need to do research beyond what’s in the letter to come to that conclusion.
That phrase in boldface should be on the first page of the letter if they were actually trying to help people.
As we have seen in the case of the guy who was refused the SS benefits he paid for, due to some supposed omission in the USedness of his father, the objective is not to help people, but to find reasons to say “no”, just like a for-profit insurance company.
To tap this one more time, does it mean Medicare payments [quote=“WatchingTheHerd, post:9, topic:106480”]
“cashed” by the lab accepting 80% of the payment… stuck the lab with 20% of the cost Medicare SHOULD have paid because “hey, by accepting the 80%, you are stating the billing is correct and the claim processing is complete.”
[/quote]
Is that the end of the story? Or, does one have to also file an appeal with Medicare to make that stick? And by “stick” does it mean it only gives time for the lab to cash the payment and thus ‘agree’ to accept that as final payment?
I think the original sequence of events in this particular example was the following:
patient requests and is granted a scan covered 100% as recommended preventative care
scan is performed by a facility who instead of submitting CORRECTSCANCODE for the procedure recognized by Medicare as “the code we should pay 100% for” submits WRONGSCANCODE that Medicare’s system maps to something else that their system is programmed to only pay 80% for.
Medicare processes the claim and electronicially remits payment to the FACILITY for 80% of the charge.
Facility’s invoicing / payment systems ACCEPT the initial 80% amount as payment, then compute the difference of the unpaid 20% and generate a bill to the patient to collect the 20% “due”.
patient receives the facility’s invoice, sees 20% due and says “dude, you should have been paid 100% of the amount – YOU the facility need to refile your paperwork with Medicare with the CORRECTSCANCODE to get your 20%”
facility attempts to do that and is told by Medicare, hey, you accepted our initial payment so the claim is closed
IN THEORY, this should be where this flow stops because the FACILITY has no right under Medicare rules to re-collect its own underbilling to Medicare from the Medicare patient.
IN REALITY, many “providers” will send additional official-looking, ominous sounding letters to patients about “outstanding balances” and “unpaid amounts” which to patients unfamiliar with actual Medicare rules can sound like the PATIENT owes the facility for the underbilled delta.
In this case, the patient doesn’t have to pay anything. They need to carefully review subsequent statements from the provider to make sure the provider doesn’t try to reclassify the prior delta from the PROVIDER’S underbilling to some new bogus charge directly to the customer . I suspect that because probably NO ONE understands how these payment rules work, particularly those that coded and tested the invoicing systems used by the facility, that this delta amount will be “stuck” for quite a while, generating additional confusion for months until someone who knows how to do it simply deletes the underbilled amount to make it vanish. In the mean time, other apsects of the provider’s automations will likely send collections threats month after month to the patient, requiring nerves of steel to ignore.
One other variable. Medicare applied the part they did not pay, in my case, to my deductable for the year. Presumably, if I had already paid my entire deductable for the year, for other things, then they would have paid all of it.
Once you file a Medicare appeal, all billing activity by the provider stops. So I’ll just file a complaint with Medicare if I get another bill. But you would need to be familar with the rules to know that.
My fear is the 98% of seniors who don’t know the rules and are vulnerable to paying money they don’t owe.
Deny what? Filing a complaint about being harrassed for payment you don’t owe isn’t a Medicare claim appeal.
There’s a 3rd level Medicare appeal that goes before an Administrative Law judge, but the amount in disput needs to exceed $180 to access that forum. Since my issue was only $19, the 2nd level appeal was the end of the line.
Note, I don’t have any problem with the appeal process. Only that the written communication Medicare sends you is too confusing. You shouldn’t have to sift through six pages of text. All the beneficiary needs to know is whether they won or lost, and how much they owe. And that should be in the first paragraph.