topic Re: Medicare denial in Wellness

Medicare denial

Goodie2shoes — Thu, 30 Jan 2020 06:37:26 GMT

As some of you already know, I had a right TKR the end of Sept 2019. So thinking all bills have been paid I get a bill the other day from a company that provided a home blood clot preventing machine ordered by the surgeon that I used as directed and sent it back to the company on the day they told me it was to be returned. I was surprised to get the bill for $300 so I called my insurance company to see if the bill was legit and find out if I indeed owed that amount. The insurance company confirmed the bill was legit so I asked why I'm just getting it. I was told the machine was denied by medicare and appealing it would be useless. I could not believe it ! This machine is ordered to prevent blood clots ! If that's not medically necessary I don't know what is !! Has anyone else had this problem with medicare? I will be calling to find out why something so necessary after this type of surgery is not a covered benefit. I called the company who provided the machine and was told they sent written medical necessity to the insurance company and it was still denied. Anyone else had this problem ? Blood clots can be a dangerous post op complication of knee replacements. Thanks for your feedback on this very important issue

Re: Medicare denial

Kachina624 — Thu, 30 Jan 2020 06:45:21 GMT

I don't recall having had any sort of blood clot prevention machine after my TKR surgery. Perhaps there's s cheaper alternative thst's commonly used? I'd talk to the doctor and ask him.

After my surgery, I got several small bills for services....cant remember what. I didn't pay them and never heard anything else about them. That was 9 years ago.

Re: Medicare denial

Mistic — Thu, 30 Jan 2020 06:58:42 GMT

I don't have an answer...But wanted to tell you that I am so sorry that you are going through this. I do hope that all can be worked out, and done quickly. This just doesn't sound right. This machine was deemed medically necessary to prevent blood clots, which are indeed very dangerous, but it was denied anyway?

DH & I are 17 months out for Medicare, and some of the things we hear do make us worry. Hoping for a Quick Resolution For you!

Re: Medicare denial

Nonametoday — Thu, 30 Jan 2020 08:15:50 GMT

@Goodie2shoes wrote:
As some of you already know, I had a right TKR the end of Sept 2019. So thinking all bills have been paid I get a bill the other day from a company that provided a home blood clot preventing machine ordered by the surgeon that I used as directed and sent it back to the company on the day they told me it was to be returned. I was surprised to get the bill for $300 so I called my insurance company to see if the bill was legit and find out if I indeed owed that amount. The insurance company confirmed the bill was legit so I asked why I'm just getting it. I was told the machine was denied by medicare and appealing it would be useless. I could not believe it ! This machine is ordered to prevent blood clots ! If that's not medically necessary I don't know what is !! Has anyone else had this problem with medicare? I will be calling to find out why something so necessary after this type of surgery is not a covered benefit. I called the company who provided the machine and was told they sent written medical necessity to the insurance company and it was still denied. Anyone else had this problem ? Blood clots can be a dangerous post op complication of knee replacements. Thanks for your feedback on this very important issue

@Goodie2shoes Have you spoken with your surgeon's office? You said you spoke to the insurance office. I am assuming you mean Medicare office. You need to speak with the surgeon's office. He/She is the one who ordered it and they would likely be able to rectify this for you if it is a covered item. I assume you are talking about pneumatic compression devices which some use in lieu of compression stockings. It is a device that presses and releases that is applied to your extremities. If your doctor felt it was necessary as opposed to the stockings, he should be able to explain to the company providing the device. I have had issues such as this, though only a couple, with my husband whereby the insurance originally did not cover it but after speaking with the physicians, they appealed to Medicare and it was taken care of. Actually, some companies would prefer losing that small amount rather than losing this doctor's business if he is a regular customer of theirs, so that might be in your favor if you appeal to him/her.

Re: Medicare denial

reiki604 — Thu, 30 Jan 2020 13:13:30 GMT

What kind of Medicare plan do you have? Is it an Advantage plan or straight Medicare with a supplemental, or just Medicare A and B? I believe different plans cover different things.

Re: Medicare denial

ALRATIBA — Thu, 30 Jan 2020 13:28:11 GMT

Never had Medicare deny a claim but recently had insurance deny pain med doc ordered from compounding pharmacy. I opted not to get the meds. By the time the whole thing was over. I didn’t need them. Tylenol was working okay.

Re: Medicare denial

Carmie — Thu, 30 Jan 2020 13:56:37 GMT

@Goodie2shoes Let me help, if I may.

I am guessing you have Traditional Medicare and a Supplement?

if so, you need to find out why Medicare denied your claim. if they did, your supplemental insurance can't cover it either. I am guessing you called your supplemental insurance plan for info?

These types of devices are covered by Medicare if they meet certain conditions.

They must be prescribed by a physician and must be medically necessary. The company who provides the device must be an approved supplier and they must participate with the Medicare program. Normally, the physician will do a predetermination to see if this device will be covered before the surgery.

You must first find out why the device was denied before you can appeal...

If it was denied as not medically necessary, you can go back to your surgeon and ask them to send in records and appeal the denial. maybe it was denied because medicare did not receive requested medical notes and records...your doctor would need to send them.

If it was denied because the supplier does not accept Medicare. You are out of luck and will get stuck paying the bill.

If you have a Medicare Advantage plan, there is still coverage for this device and again, you need to find out exactly why it was denied before you can appeal.

And yes, it is always worth appealing a claim that denied as not medically necessary....if denied because the supplier is non par with Medicare, that it is not worth appealing.

Best of luck. If you have any questions, let me know.

Re: Medicare denial

SeaMaiden — Thu, 30 Jan 2020 15:20:39 GMT

I had both knees replaced in 2013, and had no blood clot machine....my Dr. said it was not necessary....and that is with both knees done together at once. So your Dr. must be plumping up his pay check.

Always ask what is covered by insurance BEFORE accepting anything and assuming it will be covered.... you must be very proactive in your healthcare and not ASSUME ANTHING IS JUST COVERED because it is suggested.

Re: Medicare denial

chrystaltree — Thu, 30 Jan 2020 16:17:08 GMT

I didn't have one of those machines but I know a couple of people who did. Your surgeon just assumed Medicare would cover it and ordered but he should VERIFIED coverage with Medicare first and upon finding out that it was a Non Covered Service, he should have told you that. You have Medicare, you had the booklet so you must know that Medicare like every other insurer does not cover every single thing a doctor orders. Even if the doctor writes an order. Insurance doesn't work like that. Of course, you can appeal if you choose to but if you do, get a letter from the surgeon stating why he ordered it and why there was no other way to avoid a blood clot. I'm 90% percent sure that they won't over turn the denial but you can still try. Their rationale will be that the machine is "preventative". It did not "cure" or "treat" you.

Re: Medicare denial

Carmie — Thu, 30 Jan 2020 17:31:12 GMT

@chrystaltree wrote:
I didn't have one of those machines but I know a couple of people who did. Your surgeon just assumed Medicare would cover it and ordered but he should VERIFIED coverage with Medicare first and upon finding out that it was a Non Covered Service, he should have told you that. You have Medicare, you had the booklet so you must know that Medicare like every other insurer does not cover every single thing a doctor orders. Even if the doctor writes an order. Insurance doesn't work like that. Of course, you can appeal if you choose to but if you do, get a letter from the surgeon stating why he ordered it and why there was no other way to avoid a blood clot. I'm 90% percent sure that they won't over turn the denial but you can still try. Their rationale will be that the machine is "preventative". It did not "cure" or "treat" you.

A patient has no way of knowing what the doctor will order ahead of time. Many patients receive an ice cooling machine after surgery that is just sent to their home...some people have family who will fill ice bags instead. Maybe there is an important medical reason why this device was ordered for this patient.

You are speculating that you are 90% sure that this will not be covered upon appeal and they assumed it was preventative. How did you arrive at that?

These machine ARE COVERED by Medicare... Why this one was denied, we don't know that yet. Many claims are denied in error...maybe the wrong Medicare number was used or because more info is needed.

Re: Medicare denial

Carmie — Thu, 30 Jan 2020 17:33:01 GMT

@SeaMaiden How would this plump up a doctor's pay check? The doctor would not receive any more money for prescribing this.

Re: Medicare denial

SeaMaiden — Thu, 30 Jan 2020 17:53:27 GMT

@Carmie wrote:
@SeaMaiden How would this plump up a doctor's pay check? The doctor would not receive any more money for prescribing this.

many doctors accept kickbacks from medical companies ( very common with Phamacutical companies)... not something discussed or talked about.... this is done all the time. Is it right... no, but it is done.

Re: Medicare denial

GusMo — Thu, 30 Jan 2020 18:01:17 GMT

@SeaMaiden wrote:
@Carmie wrote:
@SeaMaiden How would this plump up a doctor's pay check? The doctor would not receive any more money for prescribing this.
many doctors accept kickbacks from medical companies ( very common with Phamacutical companies)... not something discussed or talked about.... this is done all the time. Is it right... no, but it is done.

Soooo not true.
we cannot even accept note pads and pens from pharmaceutical reps. When I prescribe equipment, I have no idea if it's covered or not. That detective work is up to the patient and perhaps billing/insurance person in office.

@SeaMaiden wrote:
@Carmie wrote:
@SeaMaiden How would this plump up a doctor's pay check? The doctor would not receive any more money for prescribing this.
many doctors accept kickbacks from medical companies ( very common with Phamacutical companies)... not something discussed or talked about.... this is done all the time. Is it right... no, but it is done.

Re: Medicare denial

Carmie — Thu, 30 Jan 2020 18:19:18 GMT

@SeaMaiden

Pharma and other suppliers now has to notify the government of how much money they pay to every physician every year. A lot of this has stopped. This is a much talked about subject.

You can look up your doctor to see if he/she has accepted any money from Pharma and how much. This has been in effect since 2014. It is called the Sunshine Act. If a doctor accepts more than $10, it has to be reported by Federal Law.

You can look up any provider and see if they are paying doctors on DollarsforDocs.

Re: Medicare denial

Drythe — Thu, 30 Jan 2020 18:29:56 GMT

@SeaMaiden wrote:
I had both knees replaced in 2013, and had no blood clot machine....my Dr. said it was not necessary....and that is with both knees done together at once. So your Dr. must be plumping up his pay check.

Always ask what is covered by insurance BEFORE accepting anything and assuming it will be covered.... you must be very proactive in your healthcare and not ASSUME ANTHING IS JUST COVERED because it is suggested.

@SeaMaiden

Or, it could be that you and @Goodie2shoes have different medical issues which require different treatments.

Re: Medicare denial

SeaMaiden — Thu, 30 Jan 2020 18:32:29 GMT

@Drythe wrote:
@SeaMaiden wrote:
I had both knees replaced in 2013, and had no blood clot machine....my Dr. said it was not necessary....and that is with both knees done together at once. So your Dr. must be plumping up his pay check.

Always ask what is covered by insurance BEFORE accepting anything and assuming it will be covered.... you must be very proactive in your healthcare and not ASSUME ANTHING IS JUST COVERED because it is suggested.
@SeaMaiden

Or, it could be that you and @Goodie2shoes have different medical issues which require different treatments.

@Drythe I went to a very well known joint replacement hospital here. They did not use ice machines or blood clot machines for ANYONE.

Re: Medicare denial

hckynut — Thu, 30 Jan 2020 18:50:39 GMT

@Goodie2shoes

From what you've said, I assume your surgeon did not prescribe a blood thinner after your TKR. After my wife's October TKR, her surgeon prescribed Eliquis/Pradaxa. She took this for, I believe 10 days post surgery.

Was a blood test done to determine your INR/PtoTime numbers? Having had 2 different episodes of PE(lung blood clots), I am very familiar with these readings and their importance in relation to blood clotting.

If I talk with my friend(my wife's surgeon) I will ask him if he ever prescribes this type of machine post surgery. I personally had never heard this from the many I know that have had a TKR.

Why Medicare seems it unnecessary for preventing possible blood clots? I have no idea, but I do know many older patients, are prescribed some temporary type of blood thinner, post many types of very invasive surgical procedures. I know several that were prescribed Lovenox thinner, which had to be put in via a syringe injected into the abdomen. I did that many, many times myself.

Curious to see what you find out, please post a followup.

hckynut

Re: Medicare denial

Goodie2shoes — Thu, 30 Jan 2020 19:15:18 GMT

A little update, more to come. So I am determined to find out why such an important piece of equiptment would not be covered so I called Medicare this morning and a very informed rep explained to me that they never recieved a claim from my insurance company and never would have because the insurance company is contracted to handle medicare claims and it's up to them as to what they will cover. If I had my health benefits strictly through medicare it may have been covered but insurance companies decide what they will cover and what they won't so basically I was given the wrong information. Now I have been with this insurance company for many many years, way before I retired so I decided to stay with them after I retired. The medicare rep suggested I call my carrier and speak with a supervisor.

I called my carrier, s/w a supervisor, explained what they're rep told me and what medicare said so she contacted the compression machine provider and they told her they contacted medicare who denied the equiptment and they would not be sending medical necessity to the insurance company. This is crazy ! and I intend to find out why it's not covered or get it reversed. So I called my Ortho's office, explained the situation, they will address the problem with the doctor and let me know the status of sending medical necessity to the carrier.

Re: Medicare denial

Goodie2shoes — Thu, 30 Jan 2020 19:18:07 GMT

@reiki604 wrote: What kind of Medicare plan do you have? Is it an Advantage plan or straight Medicare with a supplemental, or just Medicare A and B? I believe different plans cover different things

I have AARP Medicare Advantage complete and I have had no problems until now

Re: Medicare denial

Kachina624 — Thu, 30 Jan 2020 19:22:23 GMT

@Goodie2shoes. It's a good thing you're retired and presumably have lots of time.