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Re: Can't get answers from Medicare

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 Call Medicare Rights at 1 800 333 4114. They can be very helpful

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Re: Can't get answers from Medicare

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GailL1 you have supplied me with a lot of great information and I have a bit of reading to do!  I'm having to read it a few times and will look at your links to get a handle on what you've provided, but I think I'm getting the gist.  Evidently the 1st Dr. runs into enough coding therefore payment issues, no matter where the problem starts...........his office, medicare, contractors, patients..........with doing both procedures at the same time, that he's just avoiding any issues by doing the procedures separately and a few weeks apart.  We think!  What a shame it has to be that  complicated and fraught with error that the potential solution is the two separate surgeries. Hoping to get past this with no problems.  Thank you!

amcoffiebean
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Re: Can't get answers from Medicare

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@amcoffiebean

 

i will try to explain this as simply as I can but this is really a matter for the doctor, his coding of the procedures as the codes relate to your diagnosis(es) (possible diagnosis(es) - the actual reasons for BOTH procedures.  There is no approval for you to get as I understand - I think the 1st physician was just trying to take the easier softer way in getting both procedures done considering ease in his coding and payment, or higher payment - could be too that he doesn't understand the coding for multiple endoscopes at the same time and their relationship to each othe.

 

Medicare (CMS) works with Medicare Contractors to process claims.  These Contractors have specific rules from CMS to review and pay claims.  As I said, Medicare (CMS) makes the rules for doctors as to how claims are paid for various procedures;  the Contractors know these same rules.  It is when they aren't on the same page that confusion happens.

 

Having (2) endoscopy procedures at the same time can most definitely be done but the way they code each of them has to be determined as to whether they are related or unrelated to what is being diagnosed and sometimes treated at the same time.

 

Only your doctor understands his reasoning for wanting both diagnostic procedures - and that will determine how the codes are assigned so that the Medicare Contractor will process the claim without any questions or difficulties.

 

This is just a physician coding site blog that kind of explains it, abeit in coding terminology but I think you will get the gest of it.

AAPC - Learn Why and How to Apply The Multiple Endoscopy Rule

 

IOW - if they are related diagnostic test, one will be paid for at 100% - the other at a reduced % - I think it is 50%.  If the (2) diagnostic test are UNrelated then they could each be paid at a higher rate.  Again all of this is dependent on the coding used and the review by the Medicare contractor reviewing the claim for payment.

 

Your responsibility in all of this is to understand your health concerns and why the physician is wanting (2) test and what they are looking for in each - related or UNrelated.

You should make sure that the physician accepts Medicare Assignment, same is true for the place where you are having the surgery and the anesthesiologist too, as well as any pathologist who reads the results of any biopsies - Make sure they all accept Medicare assignment - and most DO.

 

Ask them if you will be required to sign a ABN - a Medicare Advance Beneficiary Notice. If so, why?  I don't see why they should ask you to sign one because as long as the procedures are medically necessary and coded correctly then there should be no problem.  The later (coding) is out of your hands.  

 

 

 

 

* * * * It's Always Something . . . Roseanne Roseannadanna
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Re: Can't get answers from Medicare

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GaillL1 thank you so much for taking the time to explain some of this.  I did talk to the insurance dept. of the Dr. office and they were the ones who told me I had to get an code from "my insurance company" and when I asked them to look at my file to confirm I was on Medicare and a supplement she did so then said it was still my responsibility to get a verification code from Medicare and my Medigap carrier unless I was prepared to pay if they did not.  I didn't like her response but I made 2 calls and attempts to comply with the Dr. office request, and was shut down both by Medicare and my supplement with them saying they did not do that for the beneficiary, that the Dr. office must request.  Surely the Dr. office knows that and why I feel there is something not quite right here by the Dr. office.  These will be diagnostic procedures, not preventative and I've had neither procedures previously.  I've noticed your replies here at AARP and was so glad you saw this and offered an explanation, I feel you really know the Medicare guidelines!  I've called a 2nd gastroenterologist whose insurance dept said they do both procedures at the same time regularly, but they are telling me before they schedule a first appt, they must discuss with the Dr.  I answered every question they had and now I'm mystified as to why they cannot make an appt without consulting with him.  It is so confusing to me..........yes!  I went so far as to call the surgical center where this 2nd Dr. works to make sure they are ok with doing both procedures at the same time and they are.  I will do these procedures one way or another, but I also feel the patient's safety should be considered regarding the anethesia.  I don't take being anethesized lightly!  Thank you so much for sharing your knowledge!

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Re: Can't get answers from Medicare

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Medicare serves (2) masters - the beneficiaries and the providers.

To both, they issue rules of coverage and how things are covered.

 

The reason this doctor wants to do them separately is because of the way they are paid for certain procedures or, in this case, a combination of procedures.

 

These are the instructions which CMS issues to the providers.  I know it sounds rather confusing to the patient but it shouldn't to the provider.

 

Under this definition from CMS, both procedures are included as Endoscopy.

 

CMS - National Coverage Determination (NCD) for Endoscopy

Item/Service Description
Endoscopy is a technique in which a long flexible tube-like instrument is inserted into the body orally or rectally, permitting visual inspection of the gastrointestinal tract. Although primarily a diagnostic tool, endoscopy includes certain therapeutic procedures such as removal of polyps, and endoscopic papillotomy, by which stones are removed from the bile duct.

 

Then the providers are issue detailed coverage determination instructions to the providers stating just how things are covered and what they have to do to make sure they are paid correctly.  See  instructions for Endoscopies on page 2.

 

CMS - Outreach and Education / Medicare Learning Network - Multiple Surgeries

 

Including colonoscopy at the same time is also a little confusing because this procedure can be defined as both a preventive procedure and a diagnostic procedure and the provider is paid differently for each of them depending upon the codes used to submit the claim and if you have already had the preventive procedure within the preventive procedure time frame.

 

Actually, I think it is up to the physician to get the approval, not you.

This is all very complicated for the beneficiaries and believe me, things like this and others are the reason why there are so many denials and claim disputes filed.

 

It would be so much better if Medicare could describe things like this SIMPLY to the beneficiary and for that matter even those Medicare CS reps who are talking to the beneficiaries.

 

Do what you are going to do with the 2nd opinion - if the doctor does not know the details of all of this - I bet their insurance dept. does so maybe that is who you need to talk to about doing both at the same time - because it has more to do with billing than the actual care or procedures.

 

* * * * It's Always Something . . . Roseanne Roseannadanna
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Re: Can't get answers from Medicare

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drawpoker, I'm not on Advantage. I'm on Medicare with Supplement F. I've done quite a bit of research, there should be no issue here doing both procedures at one time. The Dr. office is asking me for the authorization code to do both, telling me I have to get it from Medicare and my supplement. Medicare does not do that, so I feel it's the Dr. office making me jump thru hoops as a deterrent. I feel they may want to schedule the procedures on two different trips because they get more money from Medicare. If they'd given me a medical reason or safety reason for not doing it, that's one thing. But they did not tell me that. I've since cancelled the procedures and am looking for another Dr. Its for colonoscopy and endoscopy procedures, and it appears it is very common to do both together. I see no reason to have to be put under anesthesia twice. I'm not comfortable with the explanation I'm being given by the Dr. Medicare will pay for a 2nd opinion and I'm going to exercise that option.
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Re: Can't get answers from Medicare

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Are you in a Medicare Advantage plan?  Many MA plans do require pre-authorization for some things.  Also,  if you are in a MA,  are you sure you are using both physicians and the hospital for the planned surgeries that are within its network?   You must get prior approval to go out of network. 

 

The Medicare rep you called is correct.  They themselves do not "pre-authorize" any procedures or visits.  They go strictly by the codes the doctors submit on the claims. 

 

If you are not in a MA plan but enrolled in Original Medicare with a supplement there should be no problem.  If these proposed surgeries are deemed to be medically necessary,  what's the problem?  (You are not talking about stuff that Medicare doesn't cover,  cosmetic surgery,  breast implants,  etc etc)  are you?) 

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Can't get answers from Medicare

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Is there a group that helps decipher Medicare coverage for test procedures?  I have called Medicare twice only to be told they do not pre-authorize anything.  I've been at medicare.gov with no luck. The Dr. office is telling me I have to get authorization from Medicare to combine 2 minor surgery procedures and do on the same day.   I feel like I'm at a dead end.

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