topic Re: SO FRUSTRATED!!!! in Community Chat

SO FRUSTRATED!!!!

moon_gazer — Wed, 11 Jan 2017 00:20:27 GMT

Warning - this is a long story.

I had cataract surgery on both my eyes back in March 2016. Before having each surgery, I had to pay up front a considerable amount of money out of my pocket. I had to write a check for their clinic side and another for the surgery side. With two forms of insurance coverage, it seemed like too much. So, about 2 weeks after having both surgeries, I called the business office and inquired if they had indeed filed on both insurance policies (one being Medicare). They told me they didn't know I had Medicare and had only filed on the other insurance, even though, I had provided them with a copy of my Medicare card six months beforehand. So, they said I would be receiving a refund once they received their payment from insurance. I thought they should just go ahead and refund me and then deal with the insurance companies themselves since it had been their fault. I called every month to ask what was going on - never did they call me to let me know anything. In Sept. they relented and said they would go ahead and issue me a partial refund - said they are not supposed to issue any refunds until they, themselves, have received FULL payment . However, since I had been waiting so long, they would go ahead and do it.( For some reason, there was something that Medicare would not issue approval to pay on the second eye, even though, they had approved the very same thing on the first eye). So, in Sept., six months after my surgeries, I received a portion of what I was owed. I talked with the business manager on Dec. 28th and was told I would receive a check within a week for the remainder. Well, guess what, I'm still waiting. I have had it - going to file a complaint with the State Board of Insurance. Anyone else dealt with a similar situation - and what did you do?

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 00:31:12 GMT

OK, I was a CS rep for an insurance co for over 25 years. I need more information. It sounds like you have Primary health insurance at work or through a group plan and Medicare as your secondary insurance.

I say this because a Medicare supplement would not pay first. Let me know if this is true or not. Thanks.

Re: SO FRUSTRATED!!!!

moon_gazer — Wed, 11 Jan 2017 00:40:58 GMT

@Carmie wrote:
OK, I was a CS rep for an insurance co for over 25 years. I need more information. It sounds like you have Primary health insurance at work or through a group plan and Medicare as your secondary insurance.

I say this because a Medicare supplement would not pay first. Let me know if this is true or not. Thanks.

I have United Heathcare through a group plan as my primary and medicare as my secondary.

Re: SO FRUSTRATED!!!!

KathyPet — Wed, 11 Jan 2017 00:48:27 GMT

HAve you received the notices that are sent out by your insurance carriers (Medicare and whatever other insurance you have) showing that they have made payment on your behalf? IF payment was received from your insurance carriers and you also made payment personally then there should be a credit balance on your account which should have been refunded to you.

Re: SO FRUSTRATED!!!!

moon_gazer — Wed, 11 Jan 2017 01:00:03 GMT

@KathyPet wrote:
HAve you received the notices that are sent out by your insurance carriers (Medicare and whatever other insurance you have) showing that they have made payment on your behalf? IF payment was received from your insurance carriers and you also made payment personally then there should be a credit balance on your account which should have been refunded to you.

Yes, I do receive those notices. The eye clinic was issued payment by the insurance company(s) in April for the surgical charges on both eyes and the clinical charges on the first eye. So, that is what they refunded me in Sept. However, they are still waiting on payment for the clinical charges on my second eye. That is why they still have not refunded me for that.

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 01:04:05 GMT

Thanks for the response. I thought so, but wanted to be sure. my answer would be different if Medicare was primary.

The first thing I suggest is to request or the EOB ( explanation of benefits) from the primary insurance co. That should tell you how much was paid and what the balance is that was owed.

Next, I would call Medicare or check their website and see if and what they paid. If Medicare did not receive the bill from the clinic and doctor's office, call or visit them immediately and request that they send the claim to Medicare ASAP. Medicare claims MUST be filed by the Providers. It's the law.

If Medicare paid the claim, check to see if they paid the balance left from your insurance co. If they did, you are entitled to a full refund of your monies. If they paid a portion, subtract what was paid against what was owed. If there is a balance, you are entitled to a refund.

I'd take the EOB and the EOMB ( explanation of Medicare benefits) to the providers to prove what you should be refunded and ask them to refund your money ASAP. Threaten them with an attorney.

This would not be an insurance problem unless your insurance refused to pay or didn't pay correctly.

It sounds like the providers office staff is not on the ball and not interested in doing their work. Your beef is with them.

Personally, I would refuse to pay upfront for any medical services if I had insurance. If the providers are participating with your insurance co and Medicare, they should not have made you pay upfront. If they are out of network, they can bill upfront, but then you have to deal with reimbursement problems.

Good luck. LEt me know if you have any more questions.

Re: SO FRUSTRATED!!!!

moon_gazer — Wed, 11 Jan 2017 01:50:04 GMT

@Carmie wrote:
Thanks for the response. I thought so, but wanted to be sure. my answer would be different if Medicare was primary.

The first thing I suggest is to request or the EOB ( explanation of benefits) from the primary insurance co. That should tell you how much was paid and what the balance is that was owed.

Next, I would call Medicare or check their website and see if and what they paid. If Medicare did not receive the bill from the clinic and doctor's office, call or visit them immediately and request that they send the claim to Medicare ASAP. Medicare claims MUST be filed by the Providers. It's the law.

If Medicare paid the claim, check to see if they paid the balance left from your insurance co. If they did, you are entitled to a full refund of your monies. If they paid a portion, subtract what was paid against what was owed. If there is a balance, you are entitled to a refund.

I'd take the EOB and the EOMB ( explanation of Medicare benefits) to the providers to prove what you should be refunded and ask them to refund your money ASAP. Threaten them with an attorney.

This would not be an insurance problem unless your insurance refused to pay or didn't pay correctly.

It sounds like the providers office staff is not on the ball and not interested in doing their work. Your beef is with them.

Personally, I would refuse to pay upfront for any medical services if I had insurance. If the providers are participating with your insurance co and Medicare, they should not have made you pay upfront. If they are out of network, they can bill upfront, but then you have to deal with reimbursement problems.

Good luck. LEt me know if you have any more questions.

You are so right about the providers office staff not being on the bal and not following through with their job. That has been my main gripe all along. Everytime I have talked with the business manager (who sounds like she is about 12), she tells me that she is meeting with the chief financial officer tomorrow and will discuss everything with him. Then I wait and nothing happens. So, I call back and get some other story from her. That's why I want to know who I file a complaint with.

Thanks so much for all your information.

Re: SO FRUSTRATED!!!!

pieman — Wed, 11 Jan 2017 02:33:00 GMT

Carmie...

I have a question for you..

Medicare does not have the only 2 meds that I take, on their list//

Protonix 40 mg & Zetonna, nasal spray.

Now, I have United Health Care as my secondary, with a drug plan.

Will that take care of those 2 drugs, I haven't seen it offered with them either.

If not, can I use manufactuers coupon cards without getting in trouble?

Thank you for any info you can share,,,

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 03:35:09 GMT

@pieman wrote:
Carmie...
I have a question for you..
Medicare does not have the only 2 meds that I take, on their list//
Protonix 40 mg & Zetonna, nasal spray.

Now, I have United Health Care as my secondary, with a drug plan.
Will that take care of those 2 drugs, I haven't seen it offered with them either.
If not, can I use manufactuers coupon cards without getting in trouble?

Thank you for any info you can share,,,

I am confused. Do you have two different RX drug plans? You are only allowed to have two if they are both through an employer or other group benefit plan. If you are self pay, insurance companies are not supposed to sell you a plan if you already have one.

If a RX drug is not on your insurance plan's formulary list, you may legally use coupons or use other discounts with no problems.

All RX plans are different and you need to call Your ins. Co. to see if certain drugs are covered. There is no way to know unless you check. The benefits are not cut and dry from plan to plan or state to state like Traditional Medicare.

Re: SO FRUSTRATED!!!!

KathyPet — Wed, 11 Jan 2017 05:47:29 GMT

OK so you have received a refund for part of the money you paid up front for your surgery because your insurance company or companies paid the claim that was submitted giving you a credit balance on your account with the eye clinic/doctor but not all of the claim has been paid and it has been 9 months. have you called the insurance company to determine what the hold up is in getting the remainder of the claim paid? 9 months is a extraordinary amount of time to have a claim outstanding. WHy has the insurance company not paid the remainder of the claim? IT is certainly your responsibility to determine why the remainder has not been paid. YOu need to call the insurance company and find out what the delay is. THe clinic/doctor is not going to refund your money until they get payment from the insurance company. THey are wanting to be paid and if they do not have the insurance payment they are not going to issue you a refund. THe problem lies,with the insurance company. YOu have already said Medicare will not approve the claim for the second eye surgery and yet you want a refund . WHy will Medicare not approve the claim?

Re: SO FRUSTRATED!!!!

Moonchilde — Wed, 11 Jan 2017 05:59:21 GMT

@pieman wrote:
Carmie...
I have a question for you..
Medicare does not have the only 2 meds that I take, on their list//
Protonix 40 mg & Zetonna, nasal spray.

Now, I have United Health Care as my secondary, with a drug plan.
Will that take care of those 2 drugs, I haven't seen it offered with them either.
If not, can I use manufactuers coupon cards without getting in trouble?

Thank you for any info you can share,,,

Medicare does not cover medications. If you have a Medicare supplement for Part B, you also need to purchase a Part D supplement for prescriptions. You would need to check the formulary of all the companies offering Part D to find out who covers what; they are pretty similar.

If you have a United Health Care Medicare Advantage plan now and they don't cover the drugs, you would have to leave that plan and find another one that does cover those drugs - if you can.

Re: SO FRUSTRATED!!!!

hckynut — Wed, 11 Jan 2017 06:50:51 GMT

@moon_gazer wrote:
Warning - this is a long story.

I had cataract surgery on both my eyes back in March 2016. Before having each surgery, I had to pay up front a considerable amount of money out of my pocket. I had to write a check for their clinic side and another for the surgery side. With two forms of insurance coverage, it seemed like too much.

So, about 2 weeks after having both surgeries, I called the business office and inquired if they had indeed filed on both insurance policies (one being Medicare). They told me they didn't know I had Medicare and had only filed on the other insurance, even though, I had provided them with a copy of my Medicare card six months beforehand.

So, they said I would be receiving a refund once they received their payment from insurance. I thought they should just go ahead and refund me and then deal with the insurance companies themselves since it had been their fault. I called every month to ask what was going on - never did they call me to let me know anything.

In Sept. they relented and said they would go ahead and issue me a partial refund - said they are not supposed to issue any refunds until they, themselves, have received FULL payment . However, since I had been waiting so long, they would go ahead and do it.( For some reason, there was something that Medicare would not issue approval to pay on the second eye, even though, they had approved the very same thing on the first eye).

So, in Sept., six months after my surgeries, I received a portion of what I was owed. I talked with the business manager on Dec. 28th and was told I would receive a check within a week for the remainder. Well, guess what, I'm still waiting. I have had it - going to file a complaint with the State Board of Insurance. Anyone else dealt with a similar situation - and what did you do?

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 12:10:53 GMT

@Moonchilde wrote:
@pieman wrote:
Carmie...
I have a question for you..
Medicare does not have the only 2 meds that I take, on their list//
Protonix 40 mg & Zetonna, nasal spray.

Now, I have United Health Care as my secondary, with a drug plan.
Will that take care of those 2 drugs, I haven't seen it offered with them either.
If not, can I use manufactuers coupon cards without getting in trouble?

Thank you for any info you can share,,,

Medicare does not cover medications. If you have a Medicare supplement for Part B, you also need to purchase a Part D supplement for prescriptions. You would need to check the formulary of all the companies offering Part D to find out who covers what; they are pretty similar.

If you have a United Health Care Medicare Advantage plan now and they don't cover the drugs, you would have to leave that plan and find another one that does cover those drugs - if you can.

Medicare Part D is not a Suppliment. IT IS Medicare that can be purchased for RX drug coverage.

If you have a Medicare Advantage plan that covers RX drugs, you can't purchase another plan that also covers RX drugs.

I personally have never seen an Advantage plan that did not include some RX drug coverage.

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 12:06:03 GMT

@KathyPet wrote:
OK so you have received a refund for part of the money you paid up front for your surgery because your insurance company or companies paid the claim that was submitted giving you a credit balance on your account with the eye clinic/doctor but not all of the claim has been paid and it has been 9 months. have you called the insurance company to determine what the hold up is in getting the remainder of the claim paid? 9 months is a extraordinary amount of time to have a claim outstanding. WHy has the insurance company not paid the remainder of the claim? IT is certainly your responsibility to determine why the remainder has not been paid. YOu need to call the insurance company and find out what the delay is. THe clinic/doctor is not going to refund your money until they get payment from the insurance company. THey are wanting to be paid and if they do not have the insurance payment they are not going to issue you a refund. THe problem lies,with the insurance company. YOu have already said Medicare will not approve the claim for the second eye surgery and yet you want a refund . WHy will Medicare not approve the claim?

Yes, she should call to find out if the claim has been paid or even received.The Provider is responsible to send the claim to the insurance co. When they receive the claim, insurance will issue an EOB by law within 30 days. When there is coordination.of benefits, the providers sometimes don't follow up by submitting the claim to the secondary ins co.

My guess is that is what happened here. If Medicare does not cover something, she will get an EOB stating the claim has been denied and why. If Medicare received the claim, but needs more information to process the claim, they will notify her in writing.

Experience tells me that the clinic dropped the ball. Her account is showing paid in full on their books and they closed the account. The OP needs to light a fire under the clinic's behind to get them motivated. Her problem is quite common.

Re: SO FRUSTRATED!!!!

moon_gazer — Wed, 11 Jan 2017 15:56:58 GMT

@Carmie wrote:
@KathyPet wrote:
OK so you have received a refund for part of the money you paid up front for your surgery because your insurance company or companies paid the claim that was submitted giving you a credit balance on your account with the eye clinic/doctor but not all of the claim has been paid and it has been 9 months. have you called the insurance company to determine what the hold up is in getting the remainder of the claim paid? 9 months is a extraordinary amount of time to have a claim outstanding. WHy has the insurance company not paid the remainder of the claim? IT is certainly your responsibility to determine why the remainder has not been paid. YOu need to call the insurance company and find out what the delay is. THe clinic/doctor is not going to refund your money until they get payment from the insurance company. THey are wanting to be paid and if they do not have the insurance payment they are not going to issue you a refund. THe problem lies,with the insurance company. YOu have already said Medicare will not approve the claim for the second eye surgery and yet you want a refund . WHy will Medicare not approve the claim?
Yes, she should call to find out if the claim has been paid or even received.The Provider is responsible to send the claim to the insurance co. When they receive the claim, insurance will issue an EOB by law within 30 days. When there is coordination.of benefits, the providers sometimes don't follow up by submitting the claim to the secondary ins co.

My guess is that is what happened here. If Medicare does not cover something, she will get an EOB stating the claim has been denied and why. If Medicare received the claim, but needs more information to process the claim, they will notify her in writing.

Experience tells me that the clinic dropped the ball. Her account is showing paid in full on their books and they closed the account. The OP needs to light a fire under the clinic's behind to get them motivated. Her problem is quite common.

Believe me, I have tried to light a fire under the business manager of this clinic! You are so right - they have their money for this and they have not gotten in any hurry to refund what is due me. That is why I came here to post wondering if there is anything else I can do, short of hiring an attorney, to put the fear of God in these people. I know that eventually I will receive final payment, but I still think there needs to be some sort of repercussion to the clinic for the manner in which they have handled this whole situation. I have been a patient at this clinic for over 15 yrs., but will no longer be once this is closed.

Re: SO FRUSTRATED!!!!

moon_gazer — Wed, 11 Jan 2017 16:06:23 GMT

@KathyPet wrote:
OK so you have received a refund for part of the money you paid up front for your surgery because your insurance company or companies paid the claim that was submitted giving you a credit balance on your account with the eye clinic/doctor but not all of the claim has been paid and it has been 9 months. have you called the insurance company to determine what the hold up is in getting the remainder of the claim paid? 9 months is a extraordinary amount of time to have a claim outstanding. WHy has the insurance company not paid the remainder of the claim? IT is certainly your responsibility to determine why the remainder has not been paid. YOu need to call the insurance company and find out what the delay is. THe clinic/doctor is not going to refund your money until they get payment from the insurance company. THey are wanting to be paid and if they do not have the insurance payment they are not going to issue you a refund. THe problem lies,with the insurance company. YOu have already said Medicare will not approve the claim for the second eye surgery and yet you want a refund . WHy will Medicare not approve the claim?

I did NOT say Medicare will not approve the claim - I said, that for some reason, they had denied it. My guess is that someone in the eye clinic miss-coded it. Why would Medicare pay for a procedure on one eye and not the same procedure on the other eye?

Re: SO FRUSTRATED!!!!

pieman — Wed, 11 Jan 2017 16:11:48 GMT

Hey, Carmie..

I start my Medicare this month..

I purchased secondary insurance (United Health Care) as well as their drug program.

Neither , Medicare or United , (with the drug lists offered by them), have the 2 drugs that I listed.

So, my question is,,, if neither Medicare or United offer these 2, am I allowed to use the manufacturers coupons and get these 2 drugs on my own?

Re: SO FRUSTRATED!!!!

KathyPet — Wed, 11 Jan 2017 16:50:00 GMT

@moon_gazer wrote:
@KathyPet wrote:
OK so you have received a refund for part of the money you paid up front for your surgery because your insurance company or companies paid the claim that was submitted giving you a credit balance on your account with the eye clinic/doctor but not all of the claim has been paid and it has been 9 months. have you called the insurance company to determine what the hold up is in getting the remainder of the claim paid? 9 months is a extraordinary amount of time to have a claim outstanding. WHy has the insurance company not paid the remainder of the claim? IT is certainly your responsibility to determine why the remainder has not been paid. YOu need to call the insurance company and find out what the delay is. THe clinic/doctor is not going to refund your money until they get payment from the insurance company. THey are wanting to be paid and if they do not have the insurance payment they are not going to issue you a refund. THe problem lies,with the insurance company. YOu have already said Medicare will not approve the claim for the second eye surgery and yet you want a refund . WHy will Medicare not approve the claim?
I did NOT say Medicare will not approve the claim - I said, that for some reason, they had denied it. My guess is that someone in the eye clinic miss-coded it. Why would Medicare pay for a procedure on one eye and not the same procedure on the other eye?

HAs the medical office corrected whatever caused the original claim to be denied and resubmitted it to Medicare???

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 17:12:25 GMT

@pieman wrote:
Hey, Carmie..
I start my Medicare this month..
I purchased secondary insurance (United Health Care) as well as their drug program.
Neither , Medicare or United , (with the drug lists offered by them), have the 2 drugs that I listed.
So, my question is,,, if neither Medicare or United offer these 2, am I allowed to use the manufacturers coupons and get these 2 drugs on my own?

Yes, you can use coupons. I'd also talk to the pharmacy. Sometimes there are programs to get your drugs at no cost provided by the drug manufacturer.

Re: SO FRUSTRATED!!!!

Carmie — Wed, 11 Jan 2017 17:26:39 GMT

@KathyPet wrote:
@moon_gazer wrote:
@KathyPet wrote:
OK so you have received a refund for part of the money you paid up front for your surgery because your insurance company or companies paid the claim that was submitted giving you a credit balance on your account with the eye clinic/doctor but not all of the claim has been paid and it has been 9 months. have you called the insurance company to determine what the hold up is in getting the remainder of the claim paid? 9 months is a extraordinary amount of time to have a claim outstanding. WHy has the insurance company not paid the remainder of the claim? IT is certainly your responsibility to determine why the remainder has not been paid. YOu need to call the insurance company and find out what the delay is. THe clinic/doctor is not going to refund your money until they get payment from the insurance company. THey are wanting to be paid and if they do not have the insurance payment they are not going to issue you a refund. THe problem lies,with the insurance company. YOu have already said Medicare will not approve the claim for the second eye surgery and yet you want a refund . WHy will Medicare not approve the claim?
I did NOT say Medicare will not approve the claim - I said, that for some reason, they had denied it. My guess is that someone in the eye clinic miss-coded it. Why would Medicare pay for a procedure on one eye and not the same procedure on the other eye?

HAs the medical office corrected whatever caused the original claim to be denied and resubmitted it to Medicare???

I agree that the clinic made an error. Most if not all health insurance companies follow Medicare guidelines.

FYI.. Providers have 12 months to submit a claim after the service is rendered. I don't know the reason Medicare denied the claim... maybe the provider submitted a claim for the same eye and it denied as a duplicate?

It also could have denied because Medicare needs a copy of the EOB from the primary insurance company.

I would ask Medicare why they denied the claim if they processed it.