Topic: MD has "opted out of medicare" payments; procedure to get health insur. reimb.
bettyg
Unregistered
posted
Last 2 work days, I have spent several hours on the phone to: medicare and Iowa's BC/BS about seeing Dr. V, 4-22-06 in Minn.
Dr. V made it clear to me she "opted out of medicare" that she would NOT bill medicare on behalf of me. What she forgot to say unless I didn't hear it since I was so sleepy, was this:
"by opting out of medicare, I/patient can NOT file a claim to medicare directly for reimbursement of her 3 hr. office visit & charge for taking my blood out nor follow-up visits."
I made 3 calls each of medicare & BC/BS...very frustrating.
BC/BS kept insisting they needed a "DENIAL LETTER OR CLAIM FROM MEDICARE" BEFORE THEY WOULD ACT."
Medicare, "we can't send you a claim; ONLY THE MD can submit a claim on behalf of you and she has chosen not to by opting out of medicare therefore taking your chance to file away from you."
Last call to Wellmark/BCBS office in Des Moines, I asked to speak to the shift supervisor, a very pleasant, helpful woman. She had the same question asked of her in 15 minues...me of course. She started saying the same thing.
Then a light bulb lit up on me. Would a copy of the sheet I signed for Dr. V. saying in writing that she "opted out of medicare" do for the MEDICARE DENIAL? And I was responsible for paying the bill.... Yes!
So I asked her to tell her claim reps this so they could ask other lymies, etc. this question when talking to them. My blood pressure was getting sky high of frustration of red tape!
Asked her to send me current claim forms; she asked that I send directly to her.
Told her I had all these $3,000 of blood tests done the other day. We'll submit them to Minn. BC/BS office to see about reimbursement IF SHE IS "IN THE NETWORK" THERE! It'll be 80/20; otherwise, it won't be.
2 more boxes arrived today; total of 6 more blood, BM/urine, mouth swab, etc. left to do & send in! Too much for this mind to comprehend. This is what she told me to go to hospital & check in overnight to have the rest of these boxes done properly! So that was the 1st call I made this am; MD wasn't able to call me back.
Then I mentioned I'd be going to Wisc. MD. Is it Allergy ______ in LaCrosse?
Yes, IOWA HAS A DIRECT PLAN WITH THEM; so our bills don't have to go to Wisc. BCBS staff to process this!
Iowa does NOT pay for their allergy pills at $10/wk. Brochure said could be taken for 3-5 years. They will will cover office visit/tests!
So I ended up with a workable plan for reimubursement for my Dr. V bills.
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The problems you are having with insurance is the reason hubby opted out of medicare and stayed with private policy thru BCBS even though it costs over $700
per month -- this way he still has prescription coverage even though it is limited to $5000 per year, but out of network docs and labs are paid at 70%. Also has a stop loss where insurance pays 100% if charges go over a certain amount per year.
Unless your plan works differently than ones I know about -- if medicare denies coverage or doc opts out then your BCBS plan will NOT consider the charge and will NOT pay.
I hope for your sake I am wrong, but this is the way I understood medigap policies to work. They only pay towards charges that medicare considers.
Will keep my fingers crossed for you.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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bettyg
Unregistered
posted
Bea, thank you for your comments, and I've got my fingers crossed now too! It's a learningful, expensive adventure!
posted
That is really good to know. The first LLMD my husband saw was paid by my insurance fine until I retired. Then Medicare became primary for my husband. She did not participate in Medicare, so no denial letter from Medicare. Couldn't file with insurance. We subsequently changed doctors so this is not a problem now. However, it is good to know how to work around the problem for the future. Thanks. Ann
-------------------- Ann Posts: 66 | From Bourbonnais, IL, USA | Registered: Jan 2004
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Then a light bulb lit up on me. Would a copy of the sheet I signed for Dr. V. saying in writing that she "opted out of medicare" do for the MEDICARE DENIAL? And I was responsible for paying the bill.... Yes! ![[Cool]](cool.gif)
![[Roll Eyes]](rolleyes.gif)
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