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Old 03-15-2010, 08:18 PM   #1
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Default ? Medi care denying payment on hospital emergency

Has anyone ever encountered a claim being denyed by Medi Care for a Medical Emergency by the Attending Emergency Room Staff Physician. Medi Care stating they were not a provider at the time of the Emergency?

I greatly appreciate input from anyone that has gone through this, what did you do to resolve the problem?

Thanks,
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Old 03-15-2010, 11:52 PM   #2
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I felt the need to come back and explain why I posted the question.

It is very hard for me to go back to the night Jack fell..... this emergency had to do with that night that Jack was taken to the Hospital.

What in the world has things come to here in the United States......why should one have to ask the Hospital Attending Physician in a dire emergency situation being taken by Paramedics " ARE YOU A MEDI CARE PROVIDER" goodness gracious that is the last thing that anyone should be confronted to ask, in this emergency or any dire emergency by anyone.

How can a hospital that takes Medi Care, staff Physicians that are not a Medi Care Provider?

I am sorry to repost here but realized I needed to explain why I was asking this.

Good golly we've worked our buns off all our lives, then this with Medi Care really is upsetting. I am feeling very down and frustrated cause in the morning I have to deal with the calling and taking care of this matter, which I feel should never have to be.

I question what lies ahead for us that are on Medi Care, how are things going to be in the future, in my opinion this plan that the govenment is wanting to put forth isn't going to be there to help us, they aren't now! We've paid into it all our working lives it hasn't been free and we just recently have had an increase deductable through Medi Care. Never ever had we been confronted with a physician or medical facility being denied payment by Medi Care up untill the recent past year!!!!!!!!

We have a PPO plan but if Medi Care doesn't pay the PPO won't pay at all on the bill.

I have appreciated everyones continued prayers, God truely has been my strength, I honestly don't know how I could have managed without HIM. I couldn't have.

Thank you for continuing to pray for Jack, it hasn't been easy for him and it really is hard accepting some things in life but we just gotta push on and cope and pray for better to be.

Hugs, Patti and Jack



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Old 03-16-2010, 03:48 AM   #3
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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!
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Old 03-16-2010, 04:32 AM   #4
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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....
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Old 03-16-2010, 05:02 AM   #5
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Patti...I'm so sorry....the last thing you should have to deal with is something like this, I feel for you.

It wasn't medicare but w/our insurance when my son was born. The pediatricians group had 6 doctors, 5 of which were approved by our insurance. Months before the baby, I specifically told the drs. that Dr. X could not be our attending pediatrician for insurance purposes. Wouldn't you know it...Dr. X was on call that weekend and examined our son, we got the bill. I called and explained, reminding them of our months earlier conversation. I don't know what happened but suspect the bill got resubmitted with a different dr. listed as attending....anyway, we never got billed again.

Like others posted, don't give up, call, email, take names, be persistent (as much of a pain as it is!) and you'll most likely get it resolved in your favor.
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Old 03-16-2010, 06:13 AM   #6
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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.
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Old 03-16-2010, 07:01 AM   #7
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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!
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Old 03-16-2010, 08:37 PM   #8
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Quote:
Originally Posted by RemydeHaviland View Post
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.
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Old 03-17-2010, 04:33 AM   #9
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Quote:
Originally Posted by miabellaamoure View Post
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.
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Old 03-17-2010, 08:25 PM   #10
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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
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Old 03-17-2010, 08:42 PM   #11
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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....
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Old 03-17-2010, 11:48 PM   #12
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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.
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Old 03-18-2010, 04:07 AM   #13
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Quote:
Originally Posted by Baby Blessing View Post


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.

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


Quote:
Originally Posted by nana911 View Post
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.

..
Definitely a helpful perspective
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Old 03-18-2010, 12:45 PM   #14
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Thankful to be able to post this:The Administrator phoned me this morning, he will be speaking with the Physicians, so that I will only need to pay amount had Physicians been Authorized Medicare Providers.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
It scares me because we have witnessed some Physicians in our area that no longer want to be an Authorized Medicare Providers and are no longer treating Medicare Patients.

Medicare is making it more difficult for us people that are on it, I shiver to think of what will be for us people that have Medicare as our Primary Provider,if this plan goes through according to the cuts that will be proposed to Medicare, what in the world will we do? All of us Seniors also deserve better.

I felt it was okay to start my thread here because this is an issue that many people are getting confronted with. I hope others are able to resolve issues they have to face like we have.

Thanks everyone for your replying to our posting,

Hugs, Patti and Jack
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Old 03-18-2010, 12:56 PM   #15
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Quote:
Originally Posted by miabellaamoure View Post
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.


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.
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