Not true.
I’ve had three different eye surgery procedures since going on Medicare. I didn’t have to get authorization for ANY of them. My doctor’s office took care of getting it IF it was needed.
@lookingforward I am not going to debate with you. From your first post in this thread, you used your experience with MA coverage to interject the discussion. There is no "In some cases, it supercedes Medicare. In others, it goes by their standards. ". They do not pay if medicare denies the coverage, and pay the balance if medicare covers.
@JazzyTXMom thank you and thank you for link. I agreed with @Knowsstuff it can be very frustrating and in the case of provider, I have to sign an agreement that I be financially responsible for treatment. It was done prior to my switching to medicare, I have to check whether it is the same as the ABN and apply in general…
@thumper1 I understand what you meant, but as in other posts, we cannot assume the doctor’s office knew what is covered or not. In the case of my doctor, we signed a document that we would be financially responsible (I suspect many people do). You mentioned the doctor’s office took care of the authorization. It really makes no difference, bottom line is someone will have to get the authorization (on behalf of the patient). This went back to my initial post that in order to get that authorization which is handled by my doctor’s office, my doctor’s office scheduled me 6 weeks out.
No, I don’t think so with standard Medicare. (NOT Medicare Advantage).
Here’s more info about the Advance Beneficiary Notice – https://www.medicareinteractive.org/get-answers/medicare-denials-and-appeals/original-medicare-appeals/advance-beneficiary-notice-abn —
That practice is exactly what doctors are not allowed to do (although it might be acceptable for a lab to do so) If the ABN isn’t legit (doesn’t state the reason why a specific procedure or treatment may not be covered) – then it doesn’t protect you. A doctor isn’t allowed to bill a patient simply because there was an ABN – if Medicare doesn’t pay, it will also make a determination of whether or not the patient is subject to billing.
More links:
Patient not responsible if the ABN “Is given by the provider (except a lab) to every patient with no specific reason as to why a claim may be denied”. https://www.medicareinteractive.org/get-answers/medicare-denials-and-appeals/original-medicare-appeals/advance-beneficiary-notice-abn
“ABNs are only appropriate if the services you are providing are either noncovered or non-medically necessary.” “Medicare strictly forbids you from issuing ABNs across the board (i.e., to all Medicare beneficiaries).” https://www.webpt.com/blog/post/why-issuing-blanket-abns-is-a-no-no
I don’t know if you are confused or are just not wording things clearly – but a Medicare supplement will NOT pay for non-covered services. There is nothing for a G recipient to look at, because all G policies are the same. They pay for the patient responsibility portion of the bill that Medicare does cover – the equivalent of copays and deductibles. G pays for everything except the Part B deductible. The G carrier has no discretion in that.
A medicare supplement plan (medigap) is not like Medicare Advantage (MA). MA does work like regular health insurance, requiring pre-auths, etc. – but for those of us like Annamom who are on traditional medicare, the process is different.
That is NOT the same as a Medicare ABN and will not suffice to shift financial responsibility for a noncovered service.
You can find links to the forms that are required here: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
And again – the doctor can’t just give a blanket ABN to every patient. So that financial responsibility form you signed way back when no longer applies.
I do think that your doctor could give you an ABN for the injections, and then go ahead and give you the shots (rather than scheduling appointments 6 weeks out) – but you haven’t described that happening. In that case the doctor would be protected.
@calmom sorry… We don’t give it to everyone as a blanket form. Sorry if that was not clear. You are correct that would be wrong.
@calmom thank you. It helps.
@calmom my MA Advantage Plan doesn’t require pre-authorization for most things. My benefits are clearly outlined in my benefits booklet.
@annamom has regular Medicare. @annamom I had this as well until July. One time I did call to make sure a procedure was preauthorized…and the Medicare person politely told me that the doctors office gets this done. So I called my supplement company too…and they politely told me that the doctors offices are the ones who get the prrauthorization…not the patient.
When I was employed, the back of my BC/BS card clearly said I needed to get ER preauthorization within 24 hours of going to an ER. So…my husband was in the ER and I called from the family waiting room. BC/BS politely told me that the ER would be taking care of this.
What I’m saying…in every instance, the patient was NOT the one responsible for getting preauthorization…the medical providers were.
Does anyone here have a policy where the patient is responsible for this preauthorization?
I have never heard of a patient being required to obtain a prior authorization. In fact, as a provider, I would not count on any authorization that was not received directly from the insurance representative. Even with this, payment is sometimes denied for “no auth”.We then have to appeal with the authorization number along with the name of the rep and date of the conversation.
Some plans do require referrals from primary care providers to specialists and it is common practice that patients obtain the referral.
I wasn’t saying that MA would require pre-authorization for most things- just that it works like private insurance. When there is a question as to whether something is covered or not, the doctor or patient would go to the MA insurance for pre-auth. Typically (though not always), the MA plan also includes drug coverage as part of the same policy, so you don’t run into the Part B vs. Part D question that I think is at the heart of annamom’s problem with the injections.
It is true that the doctor/provider does have to request pre-auth for standard insurance – but it is more common that the patient will have to request this to get it done. Example: my doctor referred me for a bone scan at age 63. My insurance benefits statements says that is covered at age 65, and at age 60-64 under certain conditions. I called the insurer to ask whether it would be covered in my case, and they said preauthorization was necessary. They told me my doctor would need to request it, and explained exactly what to do. I then contacted my doctor to request that they get preauthorization. Nothing happened. My doctor later claimed that they had tried to get the authorization but never heard back from Blue Shield. I don’t believe her. In any case, I didn’t get the scan. I will get it after I turn 65, assuming Medicare will cover.
But the point is that with private insurance there is a system in place for “preauthorization” of some services which may or may not be covered depending on circumstances.
With standard Medicare + Medigap the process is different.
@thumper1, Yes, IF there is a need for pre-authorization, it is handled by the providers. What my concern was what if the service was not covered and the patients found out after the fact. In my pre-medicare days and with the financial responsibility a patient signed, a patient will be responsible, hence I think a patient will have to make sure the procedure is authorized. May be I should use “covered” instead of “authorized”. But given what I found out about ABN here, it is moot.
@calmon and @JazzyTXMom thanks.
The MA confusion predates me. I’m one who agreed, it’s M with supp G. Not MA.
And I was agreeing G covers what M doesn’t, within guidelines.
So be it.
Yes…you are talking about “covered” and that IS something you can find out.
But listen to the phone prompts carefully…because in the very first one…they say something like “information from this call is NOT a guarantee of coverage, check your plan benefits”.
If you can’t check in a book…look online. For what is covered.