Community Chat

[moon_gazer]

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]

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.

[moon_gazer]

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@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.

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

[KathyPet]

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.

[moon_gazer]

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@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.

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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. 

[Carmie]

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.

[moon_gazer]

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@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.

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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.

[pieman]

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,,,

[Carmie]

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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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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.

[KathyPet]

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?