contacting medicare for pre-authorization ?

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1

I have learned so much about medicare from this site and I hope some of you can tell me whether it is normal for the doctor to ask medicare for pre-authorization. I recently qualified for medicare and have purchased plan g which I thought would provide me reasonable coverage, but then my orthopedic’s office told me that they have to contact medicare for pre-authorization and my next appointment for an injection would be more than a month later. Before medicare, I never have to wait this long.

Here is the background.
I hurt my left knee in August. I went to see an orthopedic surgeon in September, had an x-ray, then had a MRI in October, finally the doctor suggested me to have physical therapy. So far, I have about 10 sessions of PT, not only my left knee has not gotten better, my right knee began hurting about a week ago. Hence, on the day after thanksgiving, I went to see another orthopedic surgeon in the same medical group (there are other reasons I changed doctor), he told me I have arthritis and gave me a Depo-Medrol injection on both knees and told me he needed to give me three more injections for three more consecutive weeks. But then when I made the appointment, the front office told me they have to get pre-authorization from medicare and it usually takes 3 weeks, and given it will be Christmas, therefore, the appointment won’t happen after the first week of January.

After I thought it over during the weekend, I am confused. As arthritis is common for older people and medicare is the coverage for older people, why would it need pre-authorization (I am assuming Depo-Medrol injection is common procedure)? Does it happen often to other people ?

I plan to call the office to find out the CPT code and contact medicare myself, and I will ask them if the office needs pre-authorization, why did the orthopedic surgeon give me the injection in the first place. Again, I am interested to know whether the delay is because my coverage is medicare.

2

You cannot preauthorize your own treatment, that has to come from the doctor.
Many times you can be treated at the time but ongoing services require review to see if they’re appropriate for you and you’re improving from it.
Things take time. There is some adjuster with a workload that takes time to get through all of their cases. It’s about 3 weeks for most minor things that aren’t an emergency.
Medicare doesn’t operate like private insurance all the time and they require lots of approvals and pre auths.

3

thanks. I had the wrong impression that I would get “better” insurance due to my medicare coverage. :-(.
I did not mean to preauthorize it myself. In the past, if there was any doubt, I would just get the CPT code, call the insurance company to confirm.

4

My guess is that the cortisone injection is paid under your prescription part of Medicare,(D) and like other drugs only allowed a certain time frame for a “refill”. Just a guess, not an expert.

5

I needed pre-authorization for a recent test. I have an Anthem BC/BS preferred PPO Advantage Plan. My primary care doc called them, and asked that my pre-approval be expedited. It was completed in one day and this wasn’t an emergency. It was just that the appointment had been scheduled…

I’ve been on Medicare for almost three years and never have had an issue.

6

An injection given at the providers office can be covered under Part B and since the injections I assume have to be given by the doctor and not self-administered I would imagine they will fall to Part B. There are non-covered procedures and things Medicare doesn’t cover but I wouldn’t think this would be one of them. If you do know the CPT code there are web tools that you can look up to see what Medicare will allow. There is a Physician Fee Look up tool on the CMS website and if you do know the CPT you can plug it in. Not that it would do you any good but more for an informational if you are curious on how Medicare pays certain procedures. A lot of factors that goes into claims payments so its not always as cut and dry as we want it to be.

7

Traditional Medicare does not require prior authorization for physician services which includes the injections. Rather, there is a list of covered services that providers must review to ensure coverage.

Do you have replacement plan–e.g. Aetna, Humana, etc? These plans to have an authorization process.

8

Just took a quick look because I was curious. Based on your OP this should fall to a Part B expense since the injection is administered by your doctor at their office. Most injections at the doctors office are covered under Part B assuming they are reasonable and necessary. My best guess is that the pre-certification is really just a reasonable and necessary determination. Ignore what I said in my other post about looking up the CPT on the Physician Fee look up. It will show you the injection and the National rate for that but it doesn’t allow you to add in the drug and that code is the one that would be in question. This particular injection can be used for other treatments not covered by Medicare so my guess is they just need to show that its for the arthritic knee and not for the reason medicare doesn’t cover.

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@JazzyTXMom I have the Plan G. From what I knew and I have called United Health in the past, the insurance company does not handle the authorization, they pay when medicare sends them the bill.
@dcolosi thanks for checking. When I initially google the drug, I only found it listed in the plan D, but then the doctor does not know my prescription drug plan, and when I talked to them I believed they told me they would call medicare.

@thumper1 I am not sure, but I think advantage plan may deal with authorization plan differently. When I google PT coverage, I found out that there is a fixed amount for PT under medicare coverage, but then if I have the advantage plan, I will have to contact the insurance company. (I am a newbie still learning).

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@annamom

You should have a benefits booklet for your plan. In it, it gives all the news you need to understand what you need…and when.

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I called medicare. Regarding PT, they told me from 2018, there is no limit, just that when the amount is above $2000 something, the therapist would need to add a code to certify that it is necessary. For the injection, her first response was it might be covered under plan D, but then there may be medication that are covered plan B. She told me if I have the CPT code, she could look up for me.

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@annamom Plan G is a supplemental plan plan to cover your out of pocket expenses for traditional Medicare with billing handled exactly as you describe. Since you still have traditional Medicare and not an advantage plan, there is no authorization process. Perhaps the office staff who stated they needed authorization spoke in error. I would call them and ask them to confirm that they have your insurance properly listed and ask who they need the authorization from. If there truly was an auth required, the office would have needed for the first injection as well.

13

Agreed…lots of assumptions falsely made by office staff sometimes.

I KNOW I don’t need a referral to see a specialist. And I also know I have a copay of $5 for each visit. Every single time I see a new doctor, they insist I need a referral (nope) and that I don’t have a copay (yep). Last time, I just said “please take the $5”. They reluctantly did so!

Our plan is a large group (a state retired teachers group…and no…it’s not free insurance) so we actually have dedicated phone staff to answer our questions…which is nice. Since there are about 40,000 people, that seems reasonable.

But all Medicare supplement plans and advantage plans DO have telephone help lines. And you should have a benefits book as well.

14

It’s because you have Medicare Advantage which is not typical Medicare. There are a lot of restrictions with it like limitations of doctors and hospitals. A lot of doctors do not take Medicare Advantage since it is hard to deal with. Your doctor is doing the right thing. If not, he can be the one losing out on getting paid.

https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans

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@Knowsstuff who are you talking to? The OP does NOT have a Medicare advantage plan.

I DO have one, and the restrictions you point out do not apply to my plan…at all. These plans vary just like everything else…so YMMV in terms of coverage. Mine is a preferred PPO plan. It covers any doctor who takes regular Medicare. That is a provision of the plan. It also covers any hospital that takes Medicare…which is most hospitals. My plan also has no difference between in and out of network docs…just like regular Medicare.

Please don’t make broad assumptions.

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@thumper1.Sorry …I Misread the thread quickly and I thought the OP stated they had Medicare Advantage but it was you. Not all doctors take Medicare Advantage and lots of practices are started not to take them due to restrictions on the office and increased paperwork, decreased fees etc. My office doesn’t participate in it but we take traditional Medicare.

The problem is people are being sold inferior Medicare /insurance products without seeing the total benefits. I see disgruntled patients not realizing what they purchased (this is true of traditional insurance also.) . Insurance has changed drastically in the last 5 years and I don’t think it’s for the better in my opinion.

17

Medicare supplements are alpha letters. I suspect this is Regular Medicare with a G supplement.

So OP, what do you have? Regular Medicare with a supplement or a “Medicare Advantage” policy via another company, like United? Because they operate a bit differently. The latter handles claims on behalf of the govt, with some standard aspects and some policies of their own design. Which you call (M or the company providing the M.A.) depends on which you’re enrolled with.

I have Medicare Advantage. To see a specialist, when I need authorization, sometimes, that office handles it. Sometimes they ask me to. But that means a “referral” from my primary. A no-brainer task.

I just went through this yesterday. Presto and done.

Separately, depending on your plan, some procedures can require authorization from the insurer. My doctor, lab, clinic, or hospital calls for this. They know the lingo.

I don’t think it maters if it’s Medicare B. (Part D is Rx/drugs, “Prescription Drug Coverage.”) These auths are pretty standard, unless it’s a disputable procedure or something unusual or not totally approved. Or, you’re above a limit. I suspect the office simply needs auth from Medicare for the addl Depo shots.

We can’t dismiss M.A. plans as inferior. OP is confused and can’t describe what she has. She really needs to review her manual, as thumper suggests.

Plus, how M.A. works can vary by state, state regulation and standards the state applies. Same with whether docs accept an M.A. plan, if the state allows them not to. You don’t want to scare people off a M.A. plan, when the work so well for so many. And can run so much less $$ for the services you want covered, in the manner you want that.

18

Disclaimer: I don’t know anything beyond what I can find online.

Depo-Medrol = Methylprednisolone (for short, I will just refer to it as medrol below)

Medrol appears on a list of drugs that “may be covered under Medicare Part B or D depending upon the circumstances”. The “pre-authorization” would be submission of information describing use and setting for the drug.

So basically, as near as I can figure, even though there is a general rule that injections given by doctors in their office comes under Part B, there is an exception for some “crossover” drugs. It doesn’t really require pre-authorization in the sense of determining whether or not it is covered, but it does require a pre-determination as to which entity will pay.

I’d expect a doctor would already know the answer to that question for a commonly administered drug. That is, you surely are not the first Medicare recipient being given corticosteroid injections for arthritis - and the rule as to whether covered by Part B or Part D ought to be the same in all such cases. It shouldn’t depend on the quality of your Part D plan. But unfortunately my personal expectations are not what governs the way the world runs. :frowning:

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Re: Medicare Advntage…there are MANY different levels of co enrage with these plans from outstanding to not so outstanding. YMMV even within your area.

In my state there are many companies offering MA plans…and within those companies, there are HMO and PPO plans.

Anyway…back to the OPs question. Agree with @calmom. But again…look at your benefits book and read it carefully. And as you did…use the helpline.

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@JazzyTXMom I have plan G. I don’t think there is a misunderstanding on the part of the office staff, because when she told me she needed authorization, I was surprised and reminded her I have medicare, she smiled and said she knew. Then I asked her whether she was going to call medicare, and she told me she would be and it took time.

After calling medicare myself, I also called the office, couldn’t get hold of the staff who told me she needed authorization, I was able to talk to another person, she was surprised that it took such long time for the follow up visit and told me medicare approval should be quick, she told me she would left a message for the staff member to see whether it can be scheduled earlier, regardless I am going to call them back tomorrow.

@calmom I also google Depo-Medrol and found similar result.

I am also assuming the drug is commonly used and hence I would think the office would know whether the drug is covered. One of the reasons for me to find out whether other people have similar experience is that if it were an unnecessary delay from the office, I would consider changing doctor.

@thumper1 I don’t think I have ever received the “benefits book” (if other Supplement Plan subscribers received any booket, please let me know). I got my Supplement Plan G from United Health, I called them before, they told me they do not determine what is necessary and appropriate as it would be determined by medicare and UH would just pay (I also learned the same from the other posts discussing medicare in this forum). I only received the medicare card, there is no other benefits book. I think this is one of the differences between the Plan G and the Medicare Advantage Plan, as in the case of MA, I think it is similar to the private insurance and you would receive the booklet which told you what is covered and what is not.