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Honored Contributor
Posts: 8,295
Registered: ‎06-08-2016

Re: Medicare denial

[ Edited ]

Maybe something was coded incorrectly

It's possible the diagnosis didn't match the treatment.

Did you call the insurance company or Medicare?

You have a right to an appeal.

 

Sorry you have to deal with it but I would follow through.

Keep notes of who you talk to & when & exactly what they told you.

You may  have a secondary diagnosis that was overlooked.

Have a discussion with the billing clerk at the surgeon's office.

This has probably happened before

 

 

@Goodie2shoes 

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Posts: 796
Registered: ‎04-30-2012

@hckynutwrote:

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.

Yes, I was given  blood thinner oral meds post op along with the compression machine. See my post regarding my hour conversations on the phone with medicare, my carrier and my Ortho's office. I will post a update on the final outcome. I am a retired LPN so I am very aware of the possible  post op complications and to not have this equiptment be covered is ridiculous. I am also a Type 2 diabetic !!  The MD's office staff I s/w seems to think this may be reversed   We will see, thanks

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@Goodie2shoes 

 

I am sorry you are facing this issue.

 

My DH had TKR in Nov.

 

And YES, we had that machine as well as oral blood thinners (and several other scripts). We are not on medicare, so our insurance paid for every single thing luckily.  We didn't even have to return the machine.  Saving it for knee #2.

 

We also have a ice machine thingy that wraps around his leg...he still uses this.

 

All of these were prescribed by his surgeon.

 

IMHO, your surgeon/dr did NOT order things for you excessively OR to pad his wallet.

 

 

Worse case that you have to pay for it...tell them you are only able to send a small monthly payment.  As long as you continue to make payments, they have to accept that. (NO interest or fees can be added)

 

My DD had 2 huge ambulance costs that were not fully covered on her lousy exchange med. insurance.  She paid them off in 2 years...no problems doing that.

 

Best of luck to you!

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@Respectlife   thanks for your best wishes, yes I also have the ice machine, no return needed on that. I had a compression machine with my Lft knee replacement in 2015, no issues with payment but that was before I retired. I was told by the company that provided the current  compression machine that it's rented for a cost of $2,000 total.  Nowadays you really need to have some type of medical insurance after retirement because I understand many Seniors do not have enough money to pay their bills, eat and pay for a place to stay. I am not in that type of situation  thank goodness.

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Registered: ‎03-28-2010

I never had a TKR but I've had plenty of medical things denied.  One of the biggest denials was for my daughter's speech therapy.  She was born at 28 weeks but stopped growing at 26 weeks.  After emergency c-section, she was life flighted to UCSF and was on a breathing machine.  At the age of 2, she had no vocabulary and was told by a language standard, she was more of an infant than 2 year old.  Our insurance company denied speech therapy saying it wasn't a medical diagnosis.  I had documentation from UCSF, her pediatrician, her neonatologist, speech therapist, occupational therapist and it was still denied.  I did end up taking it to a lawyer and she said we had a very good case to win but we didn't pursue it.  My husband hurt his knee real bad and needed an MRI, it was denied.  Stating he had to do physical therapy first.  I questioned that stating how can we do physical therapy when we don't know what the problem is first?  My Mom is on medicare and most of her meds are out of pocket because they're not formulary.  She spent $8000 alone on her medications last year.  One of the medications is her cancer drug (she's a breast cancer survivor).  I know you mentioned you had the surgery in September 2019 but legally they have up to a year to bill you.  Our health care system is a mess.  I was in health care for many years and saw a lot.  I am grateful I have coverage and able to see doctors and thankful for what I have.  I just wish there was a better system for all.

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Registered: ‎03-10-2010

@Goodie2shoes  I look forward to hearing how this turns out.  I know how important

a doctors coding is when submitting a charge.  Hopefully you will have a reversal

and the $300 will be covered.  Good Luck!!

 

After my TKR in Dec, I was only told to take a baby aspirin once a day for a month

to prevent a blood clot.

No ice machine was given to me (just an ice pack)....

but my doctor did bring me a single peach color rose in a vase

after my surgery..Woman Happy

 

Once again - Good Luck.  Smiley Happy

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Registered: ‎07-09-2011

@Goodie2shoes 

 

Good wishes!  I’ve spent much time working on my computer while on hold to various carriers.  Glad you ‘know the system.’ I’m sure you know, get a documentation number from everyone you speak with.

 

May I say, I have so much respect for LPNs?  While studying I observed one do a perfect (really difficult) dressing change in front of 4 Joint Commission evaluators, and one from National Medicare Review Board.  No pressure there!

"Animals are not my whole world, but they have made my world whole" ~ Roger Caras
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Best case scenario is you made it through. Worst case is it's a preventive measure and therefore is not covered. Circle back to best case scenario and pay it.

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Registered: ‎10-25-2010

Re: Medicare denial

[ Edited ]

@Goodie2shoes   From what you wrote, it appears you do not have Traditional Medicare.  You seem to have a group sponsored Advantage Plan.  If so, this type of coverage  would cover your device if medically necessary.

 

The Medical necessity information must come from your physician. It also sounds like the Medical equipment provider did not send the claim to your correct insurance company. They sent it to Traditional Medicare, which you do not have and it denied.

 

if this is the case, you should give the Medical Equiptment supplier your correct insurance info and have them submit the claim correctly with the letter of medical necessity from your surgeon

 

Now, if you were told that insurance companies can pick and choose what is covered and what is not, that is not true.  All types of insurance for people who have Medicare of every type MUST cover what Medicare Laws require and that includes the equipment for preventing blood clots.

 

Now, just in case, there is another type of insurance that can be offered by employers and it is an exception. It is not common, but it is out there.  Some companies are self insured.  They do pick and choose what they will cover and what they will not cover.  They are not subject to and rules or laws.  They pay insurance companies to administrive processing of their claims according to the company's wishes.

 

I think you need to find out exactly what type of insurance you actually have.  Traditional Medicare, Medicare Advantage or Self insured group coverage.  You may also have your employers health insurance as primary and Medicare as secondary.

 

From what I can gather, it appears your claim was not submitted correctly.  I needs to be sent to the correct insurance in order for it to get paid.

 

The medical equipment supplier probably did not get or understand the correct information from your surgeon's office.  They just assumed you had Traditional Medicare.

 

Oh, one more thing I forgot to add. Many Advantage Plans do not cover medical equipment at 100%.  You would have to pay the coinsurance.  Example: Many cover at 80% and you are responsible for 20%.  If that is what the $300 is for, you must pay it.

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Registered: ‎10-25-2010

Re: Medicare denial

[ Edited ]

@SeaMaiden wrote:

@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. 


 You know this, how?  Many people who have vascular problems are ordered this type of equipment after every surgery or whenever they are immobile.  Some people have a history of getting blood clots, even without surgery.

 

These machines are quite common and prescribed often.