Community Chat

[Moonchilde]

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@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,,,

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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.

[hckynut]

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@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?

[Carmie]

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@Moonchilde wrote:

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@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.

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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. 

[Carmie]

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@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?

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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.

[moon_gazer]

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@Carmie wrote:

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@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?

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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.

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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.

[moon_gazer]

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@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?

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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? 

[pieman]

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?

[KathyPet]

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@moon_gazer wrote:

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@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?

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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? 

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

[Carmie]

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@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?

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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.

[Carmie]

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@KathyPet wrote:

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@moon_gazer wrote:

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@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?

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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? 

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

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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.