am very afraid, nurses please help

[addiesue]

They are not allowed to charge you over the medicare amount. You should have a ship / state health insurance program that helps w these kinds of questions. To bill more is fraud, report it.

[addiesue]

http://www.hapnetwork.org/ship-locator/

[Sue Pendleton]

Originally Posted by cass

OMG got a copy of cystoscopy charges today...$11,000!! bet medicare/aetna supplemental won't come close. and i'm supposed to do this annually??

I just had one and so far all I've gotten is the report that there were no abnormal/cancerous cells in the test urine. Medicare is my primary, husband's retired work BC/BS is second and if it hits a third, rare, we have TRICARE. I don't think I saw anything in a bill from my last one at Hopkins. They accept Medicare's rate as do most teaching hospitals. I did notice that a preview coding that came with my reminder for the new provider had 4 procedure/specialists needed but $11,000 sounds like wishful thinking on your provider's part unless Oprah was coming in.

Did the biopsy hurt afterwards? I want to plan on any downtime. So far it's sounding like a colonoscopy without the prep right down to getting twilight sedation.

[cass]

no, biopsy didn't hurt, just had the same pain been having for 2 months which is driving me insane. i asked my pcp to fax order for ct scan on ovaries.

as far as medicare, yes, i am not getting what i used to w/work ins. so, at this point, was figuring out of 11k, i'd be paying. i'll find out once bills go thru medicare. already had a collection activity i had to clear up due to them. i am a medicare newbie.

thank you, everybody.

sue, my colonoscopy prep was HELL. afterwards, no prob. that was 7 yrs or so ago. the only sedation i had w/cystoscopy was epidural. they wanted to give me more to relax me, but i said no. all went well. except..pain still here and it is making me crazy.

my supplier, care medical in everett, wa, has refused to order my urocare legbags ever since my work ins. stopped. they said they can't write them off. so i've been doing with one old bag. they also said i couldn't have 2 foleys/month, i'd been getting at least that. medicare has been hell for me. and yes, i have doctor's orders for both. still can't get them under medicare. i had no worries under work ins., seems like i've had to fight for everything under medicare.

[Liz321]

Try a different supplier that will do DME work for you. If u get NM magazine check out their advertisements.

[hlh]

I understand the transition to Medicare can be very hard, very complicated, with many errors on all sides. My gut tells me that you haven't gotten the correct information.

Is your employer plan supposed to be "the same" as your insurance was when you were working, a retiree plan, or simply a "medigap plan" that only pays the 20% that medicare does not pay? You worked for an excellent employer before and I highly suspect the insurance should be better then just a Medigap. Most employer plans that continue as a medicare secondary plan are NOT the same as Medigap plans. They cover more, and usually the same as when you were working.

My Dad has Medicare primary, Blue Cross secondary from my mom's prior employer. The Blue cross plan is essentially the same insurance my mom had during work.... it is excellent, and covers much more then what Medicare does, responds more positively to appeals and is much easier to work with.

For us, this means monthly gloves, compression stockings, a bathroom transport chair, all of my Dad's accessories for his titanium wheelchair etc... My gut tells me your leg bags should be covered, if they were before. They just have to get to your secondary insurance appropriately.

How this works is that if Medicare rejects something, then it should cross over to Blue cross, and they should "pretend" like you never had Medicare and evaluate the claim as if they were primary. And pay accordingly.

In the beginning, Blue cross always rejected everything Medicare didn't cover, "forgetting" that we had the better employer Blue cross plan. Their "computer" assumed we had the standard Medigap plan and had a default for all people with Medicare primary to process all claims coming from Medicare the same. In addition, we found that when Medicare rejects a claim often it doesn't cross the claim over to Blue Cross ANYWAY. It just falls into the abyss. So you have to get the rejection, send it to Blue Cross and follow-up to get payment.

I always suspected that this was also a (hidden) attempt at Fraud by Blue Cross, as this is not a complicated computer problem to fix. Instead, many retirees are probably accepting what "the insurance company tells them".

We would have to re-submit a claim for each of the items that Medicare rejected (or ask the supplier/provider to submit the claim with medicare's rejection) to Blue cross, and then wait for approval. And it eventually happened. It takes reminders/phone calls with every single (Medicare rejected) claim, unless you can work with a provider to submit claims jointly to both insurance companies, expect the Medicare rejection and process accordingly. Since my dad gets gloves monthly, going through this process monthly was pushing me to the edge of a nervous breakdown.... but after 4 years, most months it goes through automatically now... since the provider now BELIEVES that Blue cross will pay them and they now forward bills to Blue Cross appropriately.

I'm sorry I am not explaining this well.......

Hoping that you have an advocate somewhere at the company or a retiree friend who worked there who can clarify things. Or call your secondary insurance, get a supervisor on the phone, and have them review your plan clearly as to how it works with Medicare.

I reiterate, that unless you have an incredibly high deductable in your secondary insurance plan that you ??? haven't already met for the year, then you shouldn't have to pay a penny towards this cystoscopy. Something is not right.

We really want to help you. You have enough stress to deal with. Hoping I am not making you more stressed though!!! Sorry!!!

How I wished someone had explained things when my Dad's insurance switched. He switched to Medicare (turned 65) while he was still in the ICU after his injury. It turned into living hell for me, just managing the claims.

[1 Fine Spine RN]

Cass,

I do want you to know I am out here paying attention. I will PM you. Miss you friend,

Mary

[cass]

thank you all for replying, esp. hlh for the extended explanation. i'll call aetna for clarification. the dme supplier said they couldn't bill aetna if medicare refused. and the collection activity happened when only aetna was billed, a mistake on the provider's part. it was only 80 bucks, for pete's sake, from a lab. i knew nothing about it until i got collection letter. has taken me since march to clear that up.

hi mary! got your pm, thank you!

i am in so much pelvic pain, i'm beginning to not even care about much except what's wrong. btw, peridium turned urine blood red, urobil turns it green/blue. quite the rainbow.

i just want an answer and am asking for tests. hopefully, the ct will show if i have ovarian cysts.

all i can say about ins. is i had no trouble all the years i worked. since medicare, trouble.

[hlh]

Originally Posted by cass

thank you all for replying, esp. hlh for the extended explanation. i'll call aetna for clarification. the dme supplier said they couldn't bill aetna if medicare refused. and the collection activity happened when only aetna was billed, a mistake on the provider's part. it was only 80 bucks, for pete's sake, from a lab. i knew nothing about it until i got collection letter. has taken me since march to clear that up.

hi mary! got your pm, thank you!

i am in so much pelvic pain, i'm beginning to not even care about much except what's wrong. btw, peridium turned urine blood red, urobil turns it green/blue. quite the rainbow.

i just want an answer and am asking for tests. hopefully, the ct will show if i have ovarian cysts.

all i can say about ins. is i had no trouble all the years i worked. since medicare, trouble.

I'm so sorry you are having so much pain. Hoping you get to the bottom of this soon...

Yes, Medicare can be complicated in some ways, and will never be as easy to work with as good private insurance.

I encourage you to also call your prior work benefits office and talk with someone higher up about the health care benefits. And when you call Aetna, force them to READ your specific policy to clarify your coverage, and tell them "it is an employer plan.... NOT a Medigap plan....". And when they tell you nothing useful, politely ask to speak to a supervisor. Start with general questions, then get to your leg bags.... and work out a plan on how to get them paid for long term. It will involve someone from the insurance company talking with the company where you get leg bags, and ideally, setting up a system where they can simply send the leg bag claims directly to Aetna and skipping Medicare entirely since it is an ongoing supply.

DME/Providers in general will not believe that Aetna will cover even if Medicare rejects, so again there you will sometimes need to speak with someone higher up as well and explain the same. Also, whenever you want to purchase something "big" from DME (like a wheelchair), send a pre-determination letter to Aetna to see what their coverage would be ahead of time. When a provider sees evidence that the DME will be covered (the approval letter), they are nicer about submitting the claim to Aetna after the Medicare rejection goes through. Otherwise you have to submit the claim yourself.

The reason why it is important for you to understand this system well is that if you can't CONVINCE suppliers/providers that they will eventually get paid by Aetna, they will require you to pay full price up front and get reimbursed yourself after you submit the claims yourself. Submitting claims to Medicare, getting the rejection, then sending to Aetna can take many months (and you can forget...) and can be slow and mistakes can happen. AND then when Aetna finally agrees the item is covered, they will not be willing to pay "full price". They will only reimburse you the reduced price that they would have paid the supplier/provider if they had been billed directly.

So the rules are .....

1) Never pay a bill. Almost every bill is a mistake, and the trick is figuring out who made the mistake (usually the provider made a mistake submitting the claim).

2) Always quickly ask to talk to supervisors when problems arise.

3) Try to never pay cash up front for anything.

4) When possible, use suppliers/providers that are BOTH Medicare providers AND within the "network" of Aetna.

5) If you are getting an item that you already know will not be covered by Medicare, then at least use a supplier/provider that is within Aetna's network. Submit a pre-determination letter to Aetna before you order the item, with the hope that this will convince the provider to not make you pay cash up front. Or at a minimum, ask the provider to call Aetna to confirm your coverage (that it is not a Medigap plan and covers more, and what the coverage of the specific item is).

Hang in there Cass.

[cass]

just an fyi for all out there. i got billed today for trans vag us. bill was almost 700, medicare paid 500 and change, some appeared written off, aetna paid nothing. bill is for $40 and change. yes, i'll be calling aetna. i pay something like 350/month for my work supplemental.