re post # 17. Retired physician here (not office practice). NEVER assume your physician knows about the payment mechanism for any service or drug, product et al. That’s why they have a business office. There are far too many different payment mechanisms for any physician to be aware of them all. They may have familiarity, and should have a sense of how much drugs can cost (eg generics and the latest drugs differences) but knowing the intricacies of various insurance options is not in the scope of practicing medicine.
Right, that’s why the billing specialists handle these issues, though a doc working often with certain procedures should know if there’s a question. (Eg, depending, mine will tell me to check with his rep(s) in case an auth is needed.)
But this can be YMMV.
There should have been a basic “Medicare & You” booklet for 2018 and then one for upcoming 2019. I’d assume some detailed info for the UH Plan G (or all plans.) You can usually get to a copy online, but it’s not straightforward to find. Ask UH about getting a copy.
Is the main question now, why the delay? Is it possible part of this is the auth and part is the wait for an opening with this doc?
I do have a booklet with my supplement plan (different company), but the book is in no way specific enough to answer the OP’s question. The Medicare & You booklet is also too general.
But again, I think it’s just a matter of determining whether the bill goes to Medicare or the Part D insurer. Since that is a billing issue, I don’t really see why there should be delay.
I have my Medicare and You 2019 book right here. I also have my BC/BS PPO MA booklet.
And because i haven’t tossed it…I also have the book from my former supplement plan.
The MA and supplement books are pretty detailed. The Medicare and You book is more general.
But in all cases…there is a number to call for questions.
Yes, I also have both. And I can dig into my plan’s online “Evidence of Coverage” for more details. It’s not unusual to need your PCP to need to confirm the need for a specialist. In theory, it’s broad cost oversight. In practice, for so many of us, it’s nothing to worry about, if the service is needed.
But something about the addl shots triggered a need for approval of that procedure, before the next appts. The docs want to get paid. It’s possible the delay is in that office, staff to determine and enter the codes, justify, and manage the response. Or Medicare/UH is backed up.
This isn’t a quality difference between your old plan and new. Ime, it’s a small zig that’s usually transparent. Yes, you can usually light a fire under the staff. The doc would say you need that appt in 3 weeks, not 5, and it would go from there. Or he may say, no, 5 weeks is within reason for this patient.
When I had to wait for this, when they called to tell me the approval was in, they set an appt then- sooner than the original guess. YMMV.
OP here. The person from the scheduling department I talked to yesterday called me and gave me the appointments for this week and the subsequent weeks in decemeber (instead of the initial appointments in January), she told me the office would summit to medicare and medicare would come back and say no authorization is needed as they had done it in the past.
Another reason I questioned the delay, because when I talked to the office staff in the doctor’s office, they asked me whether I had the injection in the past 6 months as medicare may deny it (I didn’t), Therefore, I assume it is beneficial to have it early rather than late.
Good to hear. This makes sense to me as traditional Medicare does not require authorization for outpatient services.
Medicare can requre authorization for some procedures or treatments. There’s a little info here
http://www.medicareadvocacy.org/prior-authorization/ And certainly, the private insurer can.
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Outpatient can mean more than a normal office visit, but not requiring a hospital stay.
Thanks for the link. I have been working on the provider side of healthcare for almost 30 years with the last 12 involving oversight of billing for physician services. In my experience, traditional Medicare has not required prior authorization for services we provide–inpatient or outpatient. Rather, Medicare has National Coverage Determinations or Local Coverage Determinations that tell us what services are covered by traditional Medicare. As long as our claim and documentation meets the criteria, payment usually follows.
Medicare advantage plans are a totally different ballgame as they are administered by private insurers and follow the rules of the payer/plan.
I am now confused with the supplemental plan. Based on the above traditional Medicare rarely required prior authorization (with some exceptions), therefore who is going to determine whether a procedure is necessary? I would assume the patent will find out when the bill is submitted. Therefore, in order to avoid an unexpected bill, the patient should find out medicare for every procedure, right?
My understanding is different; that if a doctor accepts Medicare assignment, then if Medicare doesn’t approve a procedure, the doctor doesn’t get paid for it.
I may be mistaken, but that’s what I’ve read.
The burden is on the doctor’s office to properly document the reasons for treatment.
I think your injections are covered. But likely under part D rather than B for convoluted and confusing reasons. So you might want to check your drug plan formulary, because with D there is likely some sort of copay.
“who is going to determine whether a procedure is necessary?”
The medical person/team requests appproval. The insurer can disagree. The office can ask for reconsideration.
When they said they need approval, it should have meant they need to get it. Not you.
There are procedures an insurer is likely to not approve, for various reasons. Usually that it’s an unproven treatment.
Not an unproven treatment but a treatment they don’t want to pay for. One day something is approved and the next its not. It’s where they can cut costs. Not being medically necessary doesn’t mean it’s not medically proven.
It’s more than spin the dial and pick a procedure. There can be many reasons X may not be appropriate, at this point or for this patient. Or some other procedure could be expected first.
It did seem unusual doc1 ordered an xray, mri, and pt, then doc2 announced a dx of arthritis and shots.
Sigh !! it is a different story. I will leave it for a different post.
My point is that despite medicare does not require authorization for most procedures, but in order to avoid unexpected bill, it seems that a patient does need to get authorization for every procedure.
No. All along, we’ve been saying not all procedures and not the patient. Most times, the doc office goes for the auth. If approved, then your billing depends on your specific policy.
You can’t even appropriately describe what the procedure is, in the lingo, nor do you know the exact codes.
Generally, even the billing dept doesn’t know what codes until the doc sends those over.
Imo, this is much simpler than you’re making some of it.
Read what your Plan G covers and expects. In some cases, it supercedes Medicare. In others, it goes by their standards.
@lookingforward I think you are confused with MA again.
The insurance company pays what medicare does not pay. However, they do not cover if medicare denies. Plain and simple.
If the provider believes that the service is not or may not be covered by Medicare, they are required to issue you and Advance Beneficiary Notice of Noncoverage (ABN) advising you that you may be financially responsible should Medicare deny payment. If you are not issued an ABN, the provider is not allowed to bill you should Medicare not pay. See link below for more detail:
Also to clarify, Plan G is to cover out of pocket expenses for traditional Medicare and does not have a separate list of covered benefits or standards.
@annasmom G pays for what Medicare doesn’t. But the question was, does the patient need to get auth before every procedure. That answer is still No.
And the ABN "is issued by all health care providers and suppliers when Medicare payment is expected to be denied. Different than the usual auth process. This is a financial responsibility notice.
@JazzyTXMom. You just beat me to it. Yes. But this is part of the Medicare game. Once patient sign it that they know they “could” be billed for whatever. It’s very frustrating for both providers and patients since there are actually 3 options on the form.
Problem with abn’s are its not always clear what should and should not be on the form. Yes, we have been screwed before since something we assumed would be included then was not. We make every Medicare patient basically sign one to avoid this happening. Rules change quickly. It’s really unfair when a patients needs x treatment you give it to them, then you don’t get paid for the service. There is no other occupation that this happens to… OK, I am done venting and feel better now…lol…
But if a procedure is not considered or covered by Medicare then it’s on the patient to pay for whatever it is It’s non covered service. . Doctors don’t always know but should know if common procedures are covered to some extent. 