I had a coding issue with Beaumont when I first went on Medicare. The wellness visits are covered 100% by Medicare. When I first turned 65, I mosied in for my first checkup. Received a bill from Beaumont, as Medicare had rejected the claim. I charged into the office, with Medicare paperwork in hand saying they must have coded it wrong. They deleted the charge to me, and rebilled Medicare.
A few weeks later, I received another bill from Beaumont. Medicare had, again, rejected the charge…and I read the notes on the Medicare paperwork explaining why.
I printed out the coding information from the Medicare website, and, again, charged in to the office. There are three codes for Medicare wellness visits: a code for “welcome to Medicare”, which was the visit I had, a different code for “first annual wellness visit” and a third code for “subsequent annual wellness visits”. Medicare only accepts the codes in the correct sequence. They will not accept a “first annual visit” code until after they receive a “welcome to Medicare” code, and they will not accept a “subsequent annual visit” code, until they have received cods for both the “welcome” and “first annual” visits.
When I took the information that clearly explained when to use each code in to the office, the billing person asked if she could keep it for future reference, because she had never seen that information before.
I find it hard to believe that that clinic has never had a patient on Medicare before, but they certainly acted totally ignorant of how the system works, and that was before the merger.
Steve…tired of explaining to the doc’s office how to bill Medicare
You need a business degree and a personal assistant to keep up with the paper storms created by USA Medicare as well as a lot of other shytestorm merchants, and that is not by accident but by design. The Spice Must Flow! The Sheep Must Be Sheered!
I have no trouble believing that no other patient getting cheated at that office had the knowledge, skill, and ferocity to get justice from the kept in the dark billing clerk.
Sure. But that’s the thing. If you roll into the emergency room in a coma without your personal physician in attendance, they’re not going to spend the time to review a book-length medical history to see what random lab test you had 5 years prior. At best, they’ll treat you based on the 2 or 3 items you can fit on one of those Medic Alert bracelets, if you happen to have one.
I have my medications list and relevant diagnoses typed in small print on a business card sized paper I have taped to my Medicare card. The one thing you can be sure of in an American hospital is that the first test ordered is the “wallet biopsy” to see if you’re insured and whether you’re a 5-star patient that can be billed at “out-of-network” rates.
-the billing person at the office said they would rebill Medicare on April 14th.
-on May 10th, the same person e-mailed back in response to my followup message that the case was “in billing review” and they would not rebill Medicare until the “review” is complete.
Seems you were right. They are slow walking the process, hoping I will cave. That explains why, when I checked my account on Medicare yesterday, May 23rd, there was no new billing. Meanwhile, their billing computer sent me another bill, noting “Past due Please submit payment to avoid collections.” I like the way the Brits word things in law “obtaining money with menaces”, rather than plain old “extortion”.
Learned a few things today. The limit in Small Claims Court is now $6,000. When I was in b-school, shortly after the ice age, the limit was $300. Small Claims are heard in the 16th District Court, which is in Livonia, near to casa del Steve. I don’t even need to drive into the 'hood. I could really humiliate them and sue for $1, plus withdrawing the negative information placed on my credit record, and an apology in writing, because 6 grand would not hurt them.
Steve…ornery old phart, retired, with plenty of time to pursue this.
The actual Doc I see agrees with me. I stated my case to him. He took it to the billing person in that office. She agrees with me. It’s some puzzlewit in accounts receivable that is sitting on the issue, rather than making the correction. The last place I worked at, the CFO was a big believer in the time value of money. He would jerk vendors around for months, before finally paying. RS used to take pride in paying bills promptly. When the back door of my store was rusted and warped, and not secure, I got a bid for a new door. Approved it, and sent it to the DM. He approved it and sent it to Fort Worth for payment. A week later, when the guy had received the door and was installing it, he said he had already received the check from Fort Worth, had never been paid so fast. Four years later, RS changed. When that little South Westnedge store was renovated around 92, the exterior of the building was repainted. RS jerked the painter around for months before paying him. That painter would call me up, saying he had to pay for the paint, and pay his people for their labor, but he had not seen a nickle from RS, the big, NYSE listed company. I couldn’t do anything. It was all in Fort Worth’s hands, and they had apparently discovered “time value of money” and the old ethics of paying what was due to vendors went out the window.
Back in late 1980s my cousin’s husband, a medical doctor with a private practice in LA, said to me that when he had Medicare (or was that Medicaid?) patients he would treat them for free to avoid the paperwork hassle.
I can well believe that. Although all 3rd party payors have historically had admin barriers (paper or electronic) to rebursement, Medicaid particularly has always presented too much effort for too little. Of course, back then, reimbursement was way more generous than nowadays so, as long as Medicaid recipients … and/or the uninsured … didn’t form too large a demographic in a practice, such apparent altruism wouldn’t make a dramatic difference to a practice’s bottom line as every other patient was unwittingly subsidising them…either with fees that were higher than strictly necessary in order to compensate or with padded bills that weren’t scrutinsed the way they are today.
That started to change in the 90s as employers looked for ways to trim healthcare costs, reimbursement was trimmed and a greater financial burden passed to patients themselves.
I don’t believe I have ever seen an insurance company payment for this … or infection control procedures, come to that and a host more that make for doing yer job right. There are reimbursable procedure codes, for sure, but most insurance companies bundle such line item thingies into the actual recognisable by the patient procedure code…extraction/filling/crown or whatever (I can’t even remember those codes any longer … if I ever did) Of course, one needs to make sure that those fees are high enough to cover all those “incidentals”.
In a smallish private office, one doesn’t have outside companies or a whole back room of billing staff to insulate oneself from the realities of getting the paying customer to pay. I fortunately had a practice manager who wouldn’t hesitate with pithy come back lines if patients baulked at quoted fees for future treatment… her favourite being to ask which piece of equipment would they be happy for me to re-use from the patient before them (she came up with this one herself, having worked in practices where this actually did hapen )
I have paid $100 back in 2019. The lack of coverage might be because the tests are less conclusive. The test is not about plaque.
Yet my cardiologist last year looked at the 2019 scan and told me I am completely clear of any plaque. I have a stress test this year in September. It is not urgent.
But that’s exactly what a CAC scan does show. Calcified plaque. Evidence of past disease a bit like the scars from acne. It wouldn’t show early, soft, uncalcified (more likely to rupture) lesions…because it’s a CALCIUM scan. If the conditions that precipitated this late stage situation all those years ago still exist, there’s every reason to imagine that the softer plaque is there pending further calcification.
We had this very discussion with the daughter last night. She has the follow up visit with her /our PCP tomorrow to discuss the new patient bloodwork she had done …to include Apo-b lipoprotein and the all -important, genetically associated Lp(a)
Planning ahead with far more tools in the armamentarium than in my day to prevent my situation. I hope I’ve paved the way for that since she too has been an excellent custodian of her body and, on first blush, might well look like “the sort of person” (non-fat, non-sedentary, non-smoker) who isn’t at risk from ASCVD …or the other lifestyle linked Four Horsemen … and take a back seat when it comes to initiating appropriate primary prevention strategies
I think you need a bit more education on this topic. I know I did a couple of years ago and got the heads-up up on "What I know … that just ain’t so
The Peter Attia book mentioned in a different thread would be an excellent first choice in reading matter (podcast even better) …and then this little page turner. Probably an updated version on the shelves of any of your medical family members as it’s been a standard text for quite a time, if dh’s experience is anything to go by…
Pathologists tend to credit themselves with having the most extensive experience in early clinical manifestations of ASCVD. I recall one of our lecturers back in the early 1970s making this claim. Pointed out that those early fatty streaks that coalesced to for soft plaques and ultimately the artery blocking lesions of late stage disease (that would’ve been evident on CAC scan) can be seen as early as teens and early 20s in his clients who met their demise from reasons other than “heart disease”…road traffic accidents, violence etc.
VeeEnn, you have read one or two quacks on the topic. You have not seen doctors when in my shoes. I have a higher calcification score and no plaque. If you went into a cardiologist with my condition s/he would tell you that happens.
Calcium is the most abundant mineral in the human body. Although the majority of calcium is found in teeth and bone, approximately 1% is dissolved in the bloodstream. As the human body ages, calcium can deposit in various parts of the body. Arterial calcium development is closely related to vascular injury, inflammation, and repair. Calcification occurs very early in the process of atherosclerosis; however, it is only able to be detected when it increases in quantity and using imaging modalities. This accumulation typically occurs after the age of 40 in men and women. The presence of coronary calcification is universal in all patients with documented coronary artery disease. Coronary artery calcium is most commonly evaluated by noncontrast, electrocardiographic (ECG)-gated cardiac electron beam computerized tomography (EBCT) or multidetector computed tomography (MDCT). The presence of coronary calcium score is associated with plaque burden; however, it is not a marker of plaque vulnerability. Nonetheless, it gives an insight into the patient’s level of cardiovascular disease risk and is helpful for guiding interventions or preventing coronary artery disease.[[1]]
(Coronary Artery Calcification - StatPearls - NCBI Bookshelf)[2][3][4]
The presence of coronary artery calcification is age and gender-dependent. It is present in 90% of men and 67% of women older than the age of 70.
CAD is present in about 7% of the population aged 45 to 65 years, and escalates to >20% in those 65 and older. In adults >70 years there is a progressive rise in CAD, rising to over 30% in the decades after age 70.Jan 20, 2019
Can you have a high calcium score and no blockage?
Instead, a calcium score measures the amount of calcium in your coronary arteries. It doesn’t tell us that any of your arteries are actually blocked or detect where blockages might occur. Your calcium heart score also doesn’t tell us your absolute heart attack risk.
Can you have a high calcium score but no stenosis?
Again, remember that a high calcium score does not necessarily mean that a coronary stenosis is present, although it is more likely. We also know that the plaques with little or no calcium tend to have thin, fibrous caps and are more prone to ulceration or rupture, causing an acute coronary syndrome.Feb 9, 2015 Coronary Calcium Score - No Doctor's Order?.
Now, this is totally descriptive and not a suggestion for anyone to follow but rather information for anyone who, like me, was unaware of current technology and its uses.
I think that, in order to truly visualise the anatomy of coronary arteries and the presence or absence of the softer friable plaque in addition to fibrous, calcified plaque (that used to be soft) A CATHERISATION PROCEDURE is still standard of care (say before surgical procedures) Husband had that before his bio-Bentall a few years ago. Zero plaque …soft or calcified…as confirmed at “autopsy” (of the coronary vessels that were dissected out as part of the procedure)
CT ANGIOGRAM (with contrast medium) is now taking over with folk like me and, provided there isn’t too much of a calcium burden … and yes, it’s totally possible with today’s equipment to visualize the larger deposits that’re on their way to stabilization/calcification (or to kill tou, I guess) Here’s the kicker. Absence of evidence isn’t evidence of absence. The very earliest deposits…or even those fatty streaks that herald the start of a new lesion can’t be detected. Yet.
So, with me and my honking big calcium burden, the enlightened practitioner… and
patient… tend to make the assumption that the disease progression is likely to continue if past conditions that kicked this off in the first place even though no soft plaque can be seen. In my instance, the couple of months on high dose Lipitor alone only reduced my LDL-C from around 125-135 (the highest I’ve ever seen ) to about 80 mg/dL. Inadequate to allow actual regression of the lesions (who knew THAT was possible … not I!) Hence the Repatha and an LDL-C of 35.
My cardiologist brought up the archive of the test in 2019. Tiny screen etc…but for him with all his training he was clear that all that calcium I have was not sitting on plaque.
We do not have a history of heart problems or even cancer in my family.
you are not following. They are two different tests.
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