? Medi care denying payment on hospital emergency
 

Wow! I've never heard of this before.
So is Medicare paying the facility portion of the bill, but denying the physician portion?
I hope you have been on the phone with Medicare and your PPO provider to find out how to appeal this.
I'm wondering if this was just coded in-correctly because no one would know what Dr. would be treating them for emergency care.
I think a big percentage of claims denied are due to the coding being wrong.
I really hope this gets straightened out.
I know my Mom is always having to call about her bills!

Patti, I dont know anything about Medi Care, but I do know my secretary's mother lives with her, she had to take her mother to the hospital. She had some sort of problem with medi care and her insurance, talk to the admin staff at the hospital, they do have programs that help people on medicare pay for the bills that are uncovered. I dont know the details but she kept hounding them and low and behold finally got someone who gave her the information. I hope you get it all worked out, things like that cause such undo stress....

Don't get me started on Medicare. My husband became medically disabled at 54 and was forced to take Medicare He worked for the Railroad for 38 years and the Health Insurance there was excellent. He still has his Railroad Insurance until he's 65 as a secondary. Medicare DENIES a portion of almost everything and because of this the secondary insurance denies it also because they say Medicare should pay for it. It's bad enough your sick and can't even think straight, yet you have to deal with Insurance companies which we never had to do before. We live in Connecticut he had his heart attack while driving his train to New York. He was able to get his train safely to the city (he thought he had severe heart burn) and walked into medical in Grand Central. He was taken by ambulance to the hospital, had 4 stents put in and stayed 6 days in ICU. The only money out of our pocket was for the cable television. Now we always owe something to somebody. Luckily my husband is of sound mind and he fights for every nickel and penny that is due to him. It shoudn't have to be this why. I don't know what the elderly do? The only thing I can suggest is if you think you're right and Medicare should pay, fight for it. I think too many Medicare patients don't question and just pay. Good Luck! I also think we all are in for a long battle with Medicare.

I am not entirely clear on the circumstances

If you have two plans - Medicare and a Supplement of some sort, then it sounds like confusion based on their interaction / overlap

It sounds like Medicare is denying based on the fact that another insurance plan would have been "primary", ie - Medicare was not the primary "provider of coverage"

This could be the result of a coding issue by the service provider (hospital / physician, etc), as another poster mentioned

I would investigate further and see which plan would be "primary" for emergent care

Best of luck getting things resolved!

Her husband, Jack had two coverages, Medicare as Primary and a Supplement (PPO) as Secondary. The hospital was a Medicare authorized facility although, the ER Attending Physician who cared for her husband was not.

Thus, Medicare denied payment to the ER Attending Physician because he was not an "authorized" provider of Medicare.

I would still think that Medicare part A would pay the facility portion. The physician services might be getting billed under the supplement B plan.
Bottom line, I would be on the phone with whoever you contracted your supplement through for help, I would also be contacting the hospital for assistance.

miabellaamoure Jo Ann Thank you, you explained so well what I was trying to say.

Reese1
The hopsital is a Medicare Provider Facility.

The two physicians that treated Jack were not authorized Medicare Providers. Therefore the Secondary Won't Pay.

I have called the Hospital, will be meeting with the Administrator. He definately is going to hear an ear full from me, I firmly believe the hospital should make sure their Staff Physicians are all Authorized Providers with Medicare and also other Insurances.

I will then meet with the Physicians and request a deduction in the amount which I feel is only fair (Hospitals and Physicians never get paid the full amount from any insurance company that they bill for, they use the unpaid amount for write offs) I then will go ahead and pay them.

The Private Speech Therapy Facility in the City was not signed up with Medicare. The hospitals didn't even have Speech Therapy :( Hard to understand why they don't. Thank God for giving me the strength and health and guiding me in ways to work with Jack these last nine months in helping him to relearn everything, we got a ways to go but I know God is leading and we will get there. I am so appreciative for everyones prayers, thank you.

Hugs, Patti and Jack

My DH is on Va and Medicare. The facility accepted your card and is a provider. In an emergency/trauma setting you have no choice over who the attending physician is. That decision is the hospital's. They as an approved provider would be responsible for any lapse. Charging you for something that they failed to code correctly is illogical. Doesn't really matter if the attending physician is a provider, all they should really have to do is code it correctly. If I'm not mistaken in an emergency room setting if the facility is a provider the rest really isn't so much about names as just codes and numbers pertaining to actions and treatments. If they require a name then the supervising physician who should be a provider would be all that is necessary to be listed. In most hospitals they are all interchangeable for billing purposes. This is entirely the hospital's bad.

We just got denied an ER bill by the VA because the nurse in the local ER evidently failed to notate the name of the referring person at the VA ER who referred us to the trauma center at the University hospital ER because the VA ER was understaffed on a holiday weekend. So, how's that for confusing. VA is his primary, so I can pretty much bet Medicare is gonna stamp it denied as well because protocol was not followed. So, I've got do my own tail chasing as well. Health care... hate it hate it hate it. There has got to be a better way. Actually there is. The poor and indigent have no co-pays, no denials, no deductibles, no premiums, no bills, just whip out the card and everything is 100%.. of course they won't keep getting that if we don't keep working....

I am so sorry that you are going thru this. I went thru a very similar situation when my son had to have a emergency appendectomy.

Not only was the ER Dr. not in our insurance plan, (tho the hospital is the only hospital in town, and was a covered hospital), anyway not only was he not in our plan, he "nicked" my son's bowel. He almost bled out. They had to give him 6 pints of blood. So we were responsible for payment for the TWO surgeries.

Hope you are able to get a better resolution than we were.

Good luck with this appointment and making progress toward a resolution that won't require any out of pocket payment for you.

It does sound like the facility should be responsible - and amend the coding to resubmit this properly to Medicare


Definitely a helpful perspective

That's the hospital's problem not the patients.
This happend to a co-worker too who stated the emergency
was an emergency who asks if the doc is covered by Medicare.
The hospital was responsible and covered it with a fight from
the family.

Patti - what a nightmare hospital billing can be!!!! When you visit the ER, you will always receive seperate billing statements;
1. from the hospital itself
2. from the ER physician's billing group (which is separate from the hospital)
3. possible separate bill from an outside lab/xray

Medicare is getting notorious for denying everything in the hope that people don't know what to do!!!

Every single billing agency has the ability to review charges and make adjustments based on the patients' ability to pay. However, many people don't know how to access this or whom to talk to. For a hospital, always ask for the patient advocate. For a physician, lab or xray billing, ask to speak to a billing supervisor. Unforunately, unless you are unemployed and uninsured with other monthly bills that far exceed any income, many are not going to work with you.

I hope you get this resolved. It is ridiculous for an medicare approved facility to use physicians are who are medicare providers, knowing they bill separately!!!!

Patti,

I have been reviewing my Mom's plan all day after reading about your ordeal.
I don't know the circumstances of your emergency visit & if your husband was admitted to the hospital or not.

My Mother has United Advantage HMO, not PPO. (I'm not sure if you have actually have an Advantage plan PPO or if you have the Original Medicare with Medigap/supplement policy)

Her policy regarding emergency room visits state a $50 co-pay and if non-network providers treated the emergency her insurance will work with providers to have network providers take over after the emergency is over, but she is entitled to care ANYWHERE in the case of emergencies.
I really think your insurance & hospital dropped the ball because they should have realized the Dr. was not an in-network provider.

Patti, I am so glad you were able to get it resolved. It was the last thing you needed to worry about. Prayers for your continued strength.

I work in a call center that takes calls for the er dr bills. It sounds like the hosp outsources thier er services. The company I work for supplies drs to ers across the country. When a non par dr treats someone at a participating hosp we adv to call the ins and appeal it. Tell them you had no choice of what drs to see and that the hosp is participating. Many times they will go back and pay the participating rate. Most times the dr themselves do not know whether or not they are par as they do not do their own billing. Our company takes care of all of that. It is not a matter of coding. We list the dr that signs the records. This may or may not be the person you actually saw. It would be the dr in charge while you were there. For some reason that med grp decided not to be par with medicare, it could be they could not come to an agreement with them over the contract. I deal with this every day just on the physcian's (medical) side.