| Author |
Message |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 147
Registered: 08-2008
| | Posted on Monday, March 15, 2010 - 07:29 pm: | 
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I thought that it could be helpful to share a little bit about me and my career experience in the hopes that I might be able to help promote discussions on issues related to the administrative side of healthcare. I have been working in hospital (and physician) business offices since 1975. For a period of time, I was a Privacy Officer. This gave me a better than average understanding of the HIPAA regulations. For the last 18 months I have been an independent consultant. My goal is to help business offices automate and improve their processes.
Keep in mind, my help will be based on my experience and some will be opinion only. Trust me when I say, I do not have all of the answers, but maybe with discussion we can come up with solutions. I’ll offer my experience both from a professional and a personal viewpoint. Even though I have an insider’s track, it doesn’t mean that I am able to bypass the paperwork or the approvals.
If you are having issues with your insurance, Medicare, or Medicaid benefits, I might be able to help sort them out. The paperwork and approvals needed in today’s environment sometimes cause experts to scratch their heads. Knowing who to contact and how to get help might save you time and energy. I know that both time and energy are resources that you cannot spare.
If you are having issues with your medical records or you would simply like to have a copy, I can offer advice if you experience difficulties. The short answer is that the records are yours and you are entitled to a copy. Unfortunately, there may be a “copy” fee and you will need to make your request in writing - a Release of Information request. Almost everywhere I go for healthcare I am given a copy at no charge, but it is within the healthcare facilities’ rights to charge a nominal fee. In Illinois, the fee is defined by statute.
If you are on Medicare, I can help with your understanding of Medicare benefits and give you the pros and cons of Medicare replacement policies. I can’t recommend a specific policy, but I can share what I’ve seen from the billing and claim processing end.
I am able to discuss Medicare Prescription Drug plans to some degree. These carry great benefits; however, with that comes a fair amount of complexity.
If there is enough response, I will consider sharing some of my thoughts. I think we all have a responsibility to be our own advocates.
Again, these will be opinions based upon my experience. If there are regulations that spell out the answer, I will point you to the resource. My goal is to make it easier for others to solve some of the issues surrounding healthcare benefits and records. I think that may be one reason I was fortunate enough to be blessed with the gift of life.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Rita
Forum Leader
Username: Rita
Post Number: 60
Registered: 06-2003
| | Posted on Tuesday, March 16, 2010 - 06:54 pm: |
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Hi Joe, I do not have any questions for you, BUT thank you so much for offering to help so many of us who at one time or another have been ill and the paperwork and navigating it is sometimes confusing and frustrating especially when one does not feel well. God Bless you for your kindness.
Rita
Kidney Transplant 9/95
New York City |
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Karen R.
Forum Leader
Username: Relivkaren
Post Number: 4202
Registered: 07-2007
| | Posted on Tuesday, March 16, 2010 - 09:16 pm: |
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Joe:
Wow! Thank you for offering to help those that are mind boggled by Medicare and Medicaid. I am blessed to have good insurance through my husband's company, but I am on Medicare part A just in case anything happens to Jerry's job. I know when I signed up for Medicare is was soooo confusing. I think you can help a lot of people. Thanks for caring!!
God Bless!
Karen
Dx: BOOP - May 2006. Rediagnosed with Bronchiolitis Obliterans Nov. 2006
Double lung transplant on Dec. 1st, 2009
Cleveland Clinic
Ohio, USA
Be kinder than necessary because everyone you meet is fighting some kind of battle. |
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Brenda
Member
Username: Breelee
Post Number: 15
Registered: 03-2010
| | Posted on Wednesday, March 24, 2010 - 10:55 pm: |
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joe,
I think that you are a great patient advocate. I hope people here take advantage of the help that you are offering them. Im just curious about your take on the new healthcare reform? any suggestions or advise?
COmments pro or con welcome....
thanks again,
Brenda |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 159
Registered: 08-2008
| | Posted on Thursday, March 25, 2010 - 03:33 pm: |
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Well, as with most things there are some pros and cons. The value or cost of the bill is relative to the person and their circumstances.
Personally, I am excited that there will be insurance available for almost everyone.
At every healthcare facility there are two items on their income statements that indicate the amount of charges that were written off as uncollectible.
Bad Debt - the amount that is referred to an outside collector. After sending statements and going through normal collection efforts the account has not been paid. This is usually between 2% and 5% of total charges.
Charity - The amount of charges written off because patients do not have the ability to pay. They have submitted an application with documentation of their income and expenses. Depending on the location and policy this can be up to 5% of total charges.
Bad Debt and Charity will both be impacted positively by the new rules since the number of uninsured patients will be reduced. That will reduce their total cost.
This is a positive.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Hostess Rise'
Forum Leader
Username: Risa
Post Number: 12696
Registered: 05-2003
| | Posted on Thursday, March 25, 2010 - 04:37 pm: |
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Hi Joe
Thank you so much for sharing your knowledge and expertise.
Cystic Fibrosis- dx at 2yrs. -2nd double lung tx-05 JMH
If you have any questions about this website contact Transplantbuddies@gmail.com
FaceBook
http://txbuddies.com
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Gary
Member
Username: Grser
Post Number: 21
Registered: 01-2010
| | Posted on Thursday, March 25, 2010 - 07:27 pm: |
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Hi Joe,
Do you have any insights into the SSDI System? I got a letter today saying I needed to see their people for a mental exam and to see an internist. Just curious as to what those might entail.
Thanks for your offer here to help folks...it is truly appreciated. With more information we can better advocate for ourselves...
Thanks
Gary
Pre Liver Transplant |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 160
Registered: 08-2008
| | Posted on Thursday, March 25, 2010 - 08:59 pm: |
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Hi Gary,
I have been there. I'll give you a little background on why and what you might expect.
After I was transplanted I went back to work part time in six weeks and full time in six months. I had fatigue after transplant, but thought it would get better as time passed. By the third month of full time, I realized I had gone back to work too soon. My fatigue caused me to be unable to concentrate. I could no longer do the job, so I resigned. I went to both my hepatologist and my primary care doctor, then filed a claim for SSDI. Within a few weeks, I got my letter telling me I would need to go for a mental health exam and to see an internist.
My mental health exam was benign. I was given a couple of cognitive tests, I guess to test my concentration. Memory tests, like repeating four numbers, then saying those same numbers backwards. There were lots of questions about my transplant and my state of mind. It took less than an hour. The doctor confided that I had failed the cognitive tests and she was recommending approval.
The internist was completely the opposite. The doctor I had knew nothing about the disease that caused my transplant, transplants in general, or the relationship between liver transplants and fatigue. He spent less than 15 minutes with me. Made me walk a straight line, stand on one foot, and asked a few questions.
Before I submitted my application I consulted an attorney that specialized in SSDI. I learned that there are several key factors. One is age, another is the type of work that you have done over the past ten years, and another is your medical records. He suggested that you take copies of your record that was important to your disability and highlight it and make sure it was included in your file. He said this would assure that what you wanted to be seen was brought to their attention. If I had this to do over again, I would have taken the documentation I had with me to the visit to the internist.
I was rejected and I appealed. I received the rejection from the appeal and was getting ready to go for the live hearing, when my fatigue began to improve. I also had an invitation to work with the benefit of making my own hours – as many or as few as I liked. Since I had 60 days to decide before my time limit on the appeal expired, I figured I would try work for 30 days. I started at 16 hours per week and rapidly went to 40. I now feel like a 60 year old should feel.
Keep all of your documentation and carry it with you everywhere. Be your own advocate. I would recommend an attorney who specializes in SSDI to give you guidance. Don’t expect the reviewers to see what you want them to see, give them highlighted copies.
Good luck with your journey through the process.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Gary
Member
Username: Grser
Post Number: 22
Registered: 01-2010
| | Posted on Saturday, March 27, 2010 - 01:48 am: |
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THanks Joe. That is great info. I will grab my trusty highlighter and get to work. I have worked at the same place for 37 years as both an administrator and sign language interpreter. So Hopefully I can convince them that the encepalopathy is keeping me from working in either field.
Gary
Gary
Pre Liver Transplant |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 163
Registered: 08-2008
| | Posted on Saturday, March 27, 2010 - 10:18 am: |
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Gary,
Good luck! Keep us posted on your progress.
Joe
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Gary
Member
Username: Grser
Post Number: 26
Registered: 01-2010
| | Posted on Friday, April 09, 2010 - 09:24 pm: |
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Hi Joe,
Well I finished the second of 2 evals for SSDI today. The psych person and the MD were a lot more prepared than I thought. The psych eval didn't go to well. I bit off more than I could chew by walking to the appointment. Not a good idea, got there shaking, pale and couldn't breathe. The guy got me into his office fast. I could not repeat pack the 3 words he gave me to remember after 5 minutes. He reviewed my meds, went thru my history from my file, and talked about how I was doing emotionally.
Today saw the MD. She knew a lot about encepalopathy and liver failure. Reviewed all my meds, tapped all over my abdomen, ran me thru the tests, picked up on the red palms (which I don't even notice anymore), then gave me a hand grip test. My left hand decided to have a tremor at that point and I could not grip.
As I left, She whispered I will put down you should get SSDI but SS will make the final decision. She did not look at me nor confirm that I heard her.
So, I feel they went OK. But will know in 4 - 6 weeks.
Thanks for your help and support!
Gary
Gary
Pre Liver Transplant |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 180
Registered: 08-2008
| | Posted on Sunday, April 25, 2010 - 10:35 pm: |
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Here’s another plug for everyone to get copies of their lab results, radiology reports, and surgical notes. In just my own case, I have been to my doctor’s office and my results were not in my chart. This has happened multiple times. I understand why – to some degree. My insurance requires me to go to a specific hospital for my testing. My doctor is not on staff at that hospital, so my results must be faxed instead of being retrieved electronically. Still, my results should be there, but if they aren’t how will the doctor be alerted to anomalies?
Most hospitals and labs will furnish copies of results at no charge. I keep all of my records – actually have them scanned onto a flash drive and carry them with me. This may be too much for most people, but that is the usual in some countries. With Lab results, the normal values are included with your actual values. You can determine for yourself if there is anything that needs attention. Radiology and surgical reports are filled with jargon, but both include an impression paragraph that gives the layman a good idea of what was found.
Another reason is to give you information to become you own advocate. Ask questions from your care givers. I have yet to find a physician who wouldn’t answer questions, but if I do I know I will find a new doctor.
I bring this up today for a couple of reasons, both dealing with my mother. She has not been feeling like herself since early February. I asked the Emergency Room for a copy of her Labs – they must not get that request often from the questioning look I got, but they gave me copies. I noticed that her Sodium level was low. I asked her doctor to recheck it in March and it was in the normal range. I asked again this week. Since she has been having shortness of breath and general malaise, I asked if it would be appropriate to check her Thyroid. When we picked up her results, I found that her Sodium and Thyroid were both low. Within less than 48 hours we had a new script for more thyroid and hopefully Mom will be feeling herself soon. I also found that Low Sodium can be caused by hypothyroidism. If I had not had the results, I would not have been able to ask the questions about more testing.
I do not blame the physician. The Sodium wasn’t drastically low. With the results in hand, the doctor and my Mom both became winners.
Consider getting copies of your results. It could help you or a loved one feel better
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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regscott
Member
Username: Regscott
Post Number: 5
Registered: 04-2010
| | Posted on Tuesday, April 27, 2010 - 07:05 pm: |
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Joe,
Thanks for the information. I've been doing all of these things (keeping track of my labs, copies of all my imaging studies, copies of all my doctor's notes (primary care and specialists) from the day I was diagnosed with Polycystic Kidney Disease. My first doctor recommended I do this as the military is known to lose medical records (and have lost and fortunately found them again on more than one occasion). Having them together in one place made a world of difference when I applied for VA disability and I suspect will also make a significant difference when I apply for SSDI (I just need copies of the transplant team recommendations to add to the military records) and then apply. In my case I need to apply for SSDI pre-transplant as the unusual presentation of my disease prevents any semblance of gainful employment at any level.
Ruth
Pre-dual liver and kidney
Polycystic kidney disease and Polycystic Liver Disease (PKD/PLD) |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 182
Registered: 08-2008
| | Posted on Tuesday, April 27, 2010 - 08:06 pm: |
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Thanks for your comments and good luck in your journey.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Gary
Member
Username: Grser
Post Number: 32
Registered: 01-2010
| | Posted on Tuesday, April 27, 2010 - 09:44 pm: |
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Joe,
Just wanted to thank you for your advice. I found out today that I got SSDI. It should start soon. A real load off my mind and a boon to my pocket book! Thanks!
Gary
Gary
Pre Liver Transplant |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 184
Registered: 08-2008
| | Posted on Thursday, April 29, 2010 - 10:55 pm: |
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Gary,
You are very welcome. Thank you for letting us know. Good luck and keep us posted on your journey.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Gary
Member
Username: Grser
Post Number: 49
Registered: 01-2010
| | Posted on Sunday, July 18, 2010 - 07:37 pm: |
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Thought I would give you an update. The SSDI comes in regularly YAY! Plus I had to retire as my work system is going into massive layoffs. Even tho I have worked there 38 years I would be first to go as I had been paid from grant money for most of that time. Close to 6 years ago i got a state of CA job. So they offered me a COBRA and working hourly. I was not even offered the option of working with my doctor to see if I could go half time. But at least I get a small pension and my medical and dental are covered for life. After the transplant (or before if I can get dual listing) my partner and I will move either Utah to be close to my family or New Mexico to be closer to our friends - so the cost of living will be cheaper. Thanks again Bob for all your help.
Gary
Pre Liver Transplant |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 209
Registered: 08-2008
| | Posted on Wednesday, July 21, 2010 - 09:02 pm: |
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That is truly good to hear about the SSDI. Thanks for the update.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Brian
Member
Username: Bdog
Post Number: 57
Registered: 05-2010
| | Posted on Wednesday, July 21, 2010 - 10:04 pm: |
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Joe- Do you know what the rules are for working after you get your transplant. I currently get disability and am trying to get listed for lungs. I have only worked in construction, maintenance, and factory jobs throughout my life. Jobs that I don't consider good candidates for employment with transplanted lungs, but what does Social Security think. Do you know? Right now I have 15% use of my lungs but after transplant, that number could get back to 85-90% which would be normal or better. What will SS expect of me? If my doctor says no, but my tests say I am ok as far as SS is concerned, will I loose benefits?
Thanks for any info,
Brian
Norton, Ohio
Lung Transplant Candidate
Cleveland Clinic
Emphysema
5-12-2010
Don't look back and regret,
Learn and look forward. |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 212
Registered: 08-2008
| | Posted on Sunday, July 25, 2010 - 09:53 am: |
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Brian,
To my knowledge, the SS doctors are the final authority; however, you can help to present your case to the reviewers by using asking your doctor;s help.
Everytime you visit your physician ask him if you can work. Have him document in detail why you can't. When asked for a review by SSD, then take your medical record and highlight these entries for them.
The SS administration has too many applications to review every page of every record. You need to present them with a copy that leads them to what you want them to see. They may not want your copies, but you can ask that they be added to your record. It is your right to add data to your SS record.
Now, having said all of that, I would recommend getting counsel from an attorney who specializes in SSD and has had many successful cases. I went to one when I thought I was not going to get over the fatigue and the inability to concentrate. His advice is what I gave you above.
Keep us posted and may you get the call soon.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 227
Registered: 08-2008
| | Posted on Saturday, October 02, 2010 - 11:01 am: |
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The health reform law enacts several changes at the six month anniversary of the signing. That date was September 23, 2010. What does that mean to you and I? Below are some changes that will take effect. I reviewed several sites for this information. While all of the information was related to the same changes, I found that www.pbs.org had the most readable summary. I have summarized their summary below. For the full article go to PBS Health Reform.
-- No more rescissions: Insurers will no longer be allowed to revoke patients' coverage after they become sick.
-- No more lifetime limits on coverage: Insurance policies will no longer be allowed to include lifetime dollar limits on coverage.
-- Higher annual limits on coverage: Plans will still be allowed to place annual dollar limits on coverage, but those annual limits must be at least $750,000. Annual limits will be banned completely by 2014.
-- Ban on denying coverage to children based on pre-existing conditions: Insurers will no longer be able to exclude children age 18 and under from health insurance plans based on pre-existing conditions.
-- Young adults can stay on their parents' plans: Young adults will now be allowed to remain on their parents' health insurance until age 26 -- even if they are married or are no longer a student.
-- Free preventive care: New policies must cover preventive care -- such as immunizations, mammograms and colonoscopies -- without charging a deductible or co-payment.
-- Access to ob-gyns: Women must be allowed to see in-network ob-gyns in their plans without needing a referral from a primary care doctor.
-- Access to emergency care: Insurers cannot charge customers more for using out-of-network emergency room services, or require people to get pre-authorization for emergency care.
-- New appeals process: Insurers have to implement new, more consumer-friendly claims appeals processes, including a method for submitting appeals to a third-party evaluator that could override the company's internal decision.
The provisions will go into effect for plans issued or renewed after September 23. So you'll see the changes the next time you buy a new plan, or when your new policy year begins. There are some exceptions to this so check with your insurer to confirm.
These provisions are among the first major changes of the health reform law, but they're just a first step. More provisions will phase in over the next three years, and the major changes that will restructure the health insurance marketplace and require almost everyone to carry coverage will go into effect in 2014.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 244
Registered: 08-2008
| | Posted on Saturday, December 11, 2010 - 11:47 am: |
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Today I received the "new" provisions of my health insurance plan. The annual limit has been raised to $5 million and the lifetime limit has been abolished. While I hope the limits will not be tested, I am happy that I no longer need to be concerned about them.
I urge you all to check your plan. Any plan that has been renewed since 9-23-2010 must follow the provisions in my previous post.
Joe Berry, Peoria, IL USA
Forum Leader
Diagnosed with PSC and UC in 1990
Liver Transplant 10-17-2007
Northwestern Memorial, Chicago, IL |
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Susie
Member
Username: Dachsiefan
Post Number: 2
Registered: 04-2011
| | Posted on Saturday, April 09, 2011 - 09:05 pm: |
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Hi Joe,
I have been a liver transplant candidate at Northwestern Memorial Hospital since 2008. I was granted SSDI in March 2009 after two rejections when I engaged the services of a social security lawyer. I became eligible for Medicare in Septembeer 2010 and enrolled in Original Medicare and a Blue Cross Blue Shield of Illinois Plan F Supplement plan as well as a Medicare Part D Plan.
In September an MRI of my liver showed growth of a lesion which had previously been stable. My hematologist Daniel Ganger order ct scans of my abdomen, thorax, and pelvis and a full nuclear body scan to rule out cancer. Medicare approved NMH's bill for the CTs, but denied the doctor's bill from Northwestern Memorial Facualty Foundation for the thorax CT. They ruled it was not a medical necessity. I have filed an appeal with Medicare. I had the transplant center write a letter stating it was medically necessary and included it with my paperwork. My appeal is currently under review.
On my MSN, Medicare states "It appears you did not know we would not pay for this service, so you are
not liable. Yet, I have already received a bill from NMMF for the full amount of the doctor's bill. In the event Medicare does not grant my appeal, do I believe Medicare or have to pay NMFF?????
Another insurance question: In February of this year, I had a tips procedure to remove a portal vein clot and reestablish blood flow to my portal vein. I was hospitalized after the procedure. On the same day, I had two different doctors bill Medicare for initial hospital care using the same code. Medicare paid approved and paid them, but my supplement plan denied payment for one of the doctors because they deem it to be a duplicate. I think this is because the provider and service provided numbers were the same. I called BCBS and told them one of the doctors was treating my liver and the other, was a hematologist who was brought into consult and that Medicare had approved and paid b9th of them to no avail. Do you have any advice?
In addition to schedule biweekly labs and quarterly procedures, keeping track of the insurance payments has become a full time job. Some days I am feeling up to it. Other days, my fatigue and HE are too limiting.
Susie
Giant cell (NeoNatal) Hepatitis
Cirrhosis and ESLD
Meld 14
Age 49 |
Susie
Member
Username: Dachsiefan
Post Number: 3
Registered: 04-2011
| | Posted on Sunday, April 10, 2011 - 10:33 am: |
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Joe,
Sorry for all the typos in my post. My typing and proofreading skills are not what they used to be.
Susie |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 258
Registered: 08-2008
| | Posted on Wednesday, April 27, 2011 - 10:55 am: |
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Susie,
I am so sorry it took me this long to respond.
First the payment to the Northwestern Memorial Medical Foundation. If Medicare states that the bill is not due from you on your EOB from them, NMMF cannot bill you. It is a part of the Medicare regulation. I urge you to contact them and explain exactly what you wrote here. I would think that they would immediately discontinue billing you. Please write again if that is not the case. By the way, it is unusual for Medicare to approve the hospital and not the physician, but NMMF does bill a little differently than most organizations when it comes to professional fees.
As for your denial from BCBS, I would send them copies of the Medicare approval for both services. Ask them what they need to pay the second claim. I too have BCBS and needed a letter from my doctor once to get a claim paid that they had denied. Unless there is a specific exclusion in your plan, the supplemental policy usually pays if Medicare pays.
I go to Northwestern also and have found them to be good at billing and when they do make an error, they are fast to correct it..
I know what you mean about it being a full time job keeping track of Medicare/insurance payments. Health care is way too complex.
Good luck and keep me posted. If NMMF should not see things as I do, there may be other avenues for resolution.
PS: Don't worry about typos - until I saw your second post, I didn't see any typos.
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Susie
Member
Username: Dachsiefan
Post Number: 4
Registered: 04-2011
| | Posted on Wednesday, April 27, 2011 - 11:34 am: |
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Dear Joe,
Thank you for your thoughts.
Medicare sent me a letter yesterday saying my appeal was denied because:
the diagnosis code billed is non-covered
for your service to be covered, the medical need must be supported by an accepted reason
your diagnosis does not support payment of this service. We found your service was not
reasonable and necessary based on LCD L28544
we told your doctor through a Medicare Policy that this service may not be paid. Since your
doctor knew Medicare would not pay for this service, Medicare cannot pay. Your doctor is
liable for the charges.
I called NMFF's billing department to make them aware of Medicare's rejection of my appeal. They insisted I was liable for the charge. I called Medicare and they told me it was against the law for NMFF to bill me for this service. I called NMFF patient services department and explained the problem to one of their staff. I am faxing her a copy of my appeal and Medicare,s denial today. I told her I was trying to get them paid for the service and I was treated unprofessionally by their billing department. Here I am at home, getting intravenous antibiotics for yet another kidney/UTI infection, and I have to deal with this.
AAAARRRRRRGGGGGHHHHHH!!!!!!!!!!!!
Thanks for the suggestion regarding blue cross and blue shield. If I am feeling up to it, I might put together a packet for them later this week.
Susie
Giant Cell Hepatitis
ESLD
Meld 16
Age49 |
Bob2006
Member
Username: Delgador
Post Number: 210
Registered: 06-2008
| | Posted on Wednesday, April 27, 2011 - 11:54 am: |
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Hi Susie,
I had similar issues with procedures done at home that Medicare would not pay for simply b/c they don't cover it "at home", so I had them done at clinic instead and Medicare covered them.
Bob
Liver TX 7/31/2006 due to HCC
Dr. Jang Moon & Dr. Andreas Tzakis - UM/JMH |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 259
Registered: 08-2008
| | Posted on Wednesday, April 27, 2011 - 12:16 pm: |
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Susie,
If NMMF did not have you sign an ABN (Advanced Beneficiary Notice) prior to receiving services, they can not bill you for them - period! The LCD stands for Local Coverage Determination. Most health care organizations now have an automated way to check for coverage prior to service, That way, if it is not a covered service then they can get an ABN signed.
If you do not get the expected response - an apology for billing you for something that shouldn't have been billed, the next person to contact would be their Compliance Officer or the manager of their billing department. I would choose the Compliance Officer. What you are dealing with is wrong and Compliance Officers know how wrong it is.
Good luck and let me know how it turns out.
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Susie
Member
Username: Dachsiefan
Post Number: 5
Registered: 04-2011
| | Posted on Wednesday, April 27, 2011 - 06:39 pm: |
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Joe,
I do not remember signing an ABN prior to having my ct scans that day. The only ABN's I have ever signed are from Quest Diagnostics telling me I may have to pay for my INR blood test since I get them more often than Medicare thinks is necessary, but I have to have it every two weeks to comply with UNOS and stay on the waiting list.
The kicker for today? I got another bill from NMFF today for the disputed professional charge!!!!!
Susie
Giant Cell Hepatitis
ESLD
Meld 16
Age49 |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 260
Registered: 08-2008
| | Posted on Wednesday, April 27, 2011 - 07:06 pm: |
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Susie,
Since it is unlikely you signed an ABN, I think that you should put your complaint in writing. Send it to the Director of the Billing department and the Compliance Officer. Putting it in writing allows you 30 days with no harm to your credit rating and allows them time to resolve the problem.
If this does not do the trick, report them to Medicare.
Good luck and keep us posted on the progress.
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Susie
Member
Username: Dachsiefan
Post Number: 6
Registered: 04-2011
| | Posted on Thursday, May 05, 2011 - 05:45 pm: |
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Hi Joe,
NMFF called my voice mail yesterday and told me that my balance was zero! In today's mail, I got a new EOB from BCBS, and it paid the disputed duplicate charge. All this transpired while I was in the hospitlal for 3 days with low potassium and magnesium levels due to a diuretic my urologist put me on.
NMFF's change of heart came "coincidentally" after I sent them a certified letter regarding my Medicare problem!
Thanks for your help.
Susie |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 261
Registered: 08-2008
| | Posted on Thursday, May 05, 2011 - 07:31 pm: |
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Susie,
Thanks for updating the situation. It is "coincidental".
I am glad that it is settled - now you can concentrate on your health.
Be well and thanks again for the update.
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Hostess Rise'
Board Administrator
Username: Rise
Post Number: 16143
Registered: 05-2003
| | Posted on Friday, May 06, 2011 - 02:07 pm: |
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Thank you Joe for all you do by educating us  on healthcare
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 262
Registered: 08-2008
| | Posted on Saturday, May 07, 2011 - 08:58 pm: |
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You are very welcome - glad to help.
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Brian
Member
Username: Bdog
Post Number: 118
Registered: 05-2010
| | Posted on Monday, May 30, 2011 - 11:07 pm: |
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Hello Joe,
I hope this finds you well and healthy.
I have a Medicare question for you if you don't mind.
I am currently pre-TX, on SSDI, and am covered by my wife's health care insurance from her employer. In Dec. of this year I will become eligible for Medicare. I am 44 years old, have 14% lung function, but the doctors tell me it is still too soon to list. Although I do get around pretty well, I like to have all my ducks in a row if possible.
Now, I have been told many conflicting stories about what I should do when it comes time for me to sing up for Medicare. Soc. Sec. told me that, because my wife's employer is so large, her medical insurance will be my primary and Medicare A will be secondary. This is also what United Health Care, which is my wife's insurance. Where I get confused is Medicare B. Soc. Sec told me that if I elect for Medicare B, then Medicare becomes my primary, and my wife's becomes secondary, and I will have to get prescription coverage somewhere else (possibly my wife's ins.). Another problem is, I have been told by TX patients that Medicare B is what pays for the TX drugs that are necessary, and to make sure I sign up for part B ASAP. MY wife's ins. does cover all the drugs that I have looked up; that I have come to know as TX drug; but with deductibles, that, if there is enough of them, could get quite expensive. One other problem is, our "in-network" pool is quite large and I do not want to loose that, and we rarely have to fight to get a bill paid. They OK'd the pre-TX authorization with no questions.
I guess the looming question in all of this is, What, in your opinion, should I do about Part B.? I think you have to pay a penalty if you don't accept it within a certain time frame, and I am really trying to make this whole thing as easy on my family as I can. I feel like a burden as it is, and don't want it to become a monetary burden also. If you could give ant insight, it would be greatly appreciated.
Thank You,
Brian
Norton, Ohio, USA, Northern Hemisphere, Earth
Lung Transplant Candidate
Cleveland Clinic
Emphysema
5-12-2010
Don't look back and regret,
Learn and look forward. |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 267
Registered: 08-2008
| | Posted on Thursday, June 02, 2011 - 04:32 pm: |
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Hi Brian,
Let me answer the easy questions first. For both Medicare A and B, your wife’s group insurance will be primary. There is no difference in how Medicare A and B handle the coordination of benefits. A good fact sheet is located here: https://www.cms.gov/MLNProducts/downloads/MSP_Fact_Sheet.pdf. This document is meant for providers, but it is the best one I have found because it is short and to the point.
You will still be able to choose your providers based on the UHC network.
As for the Medicare B question, I just don’t know. Some questions to consider are how long your wife will have the coverage she has and what the benefit differences are for the Part B services. Part B covers transplant drugs only if Medicare paid for the transplant. I do not know how they view being the secondary payor. Medicare Part D (Prescription Drug Coverage) does cover transplant meds (depending on the plan). You may not need this at all as long as your wife has her coverage. I recommend asking these questions at a local Social Security office and see where they point you. Do not just call the Medicare helpline. You can call there, but ask for a supervisor. This is a very specialized question and their first level staff is more than likely not equipped to handle this question. It may well take a benefits expert in transplants to provide the answer.
Brian, while it is somewhat natural to feel like a burden, I assure you that your family doesn’t view it that way. Their love is unconditional and sometimes we (patients) just have to think about that and react accordingly. That is, accept it and thank them for their continued support.
I am sorry I don’t have the answer to all of your questions, but I would like to know what you find out about Part B. Also, be aware that when you sign up for Medicare that several Medicare Advantage companies will pop out of the woodwork and want you to replace your Medicare coverage with theirs. Be very careful before signing anything. Some Advantage plans are great, but some are not.
I have listened to several talk to my in-laws. They are paid when they sell, so it sometimes becomes a total sales pitch without regard for your well being.
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Brian
Member
Username: Bdog
Post Number: 119
Registered: 05-2010
| | Posted on Thursday, June 02, 2011 - 11:05 pm: |
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Thanks Joe,
I was starting to think that this was a very unique situation, and that is why I was getting so many different answers. Like you said, even when I talk to Soc. Sec, I talk to lower level employees that give "blanket" answers. When I speak to other transplant patients, they were old enough to receive Medicare and had no other options but medicare. I will keep up with the digging and definitely post everything I find out in hopes that it will help others in my situation. Thank you for taking the time to reply and getting as much info as you could.
Brian
Norton, Ohio, USA, Northern Hemisphere, Earth
Lung Transplant Candidate
Cleveland Clinic
Emphysema
5-12-2010
Don't look back and regret,
Learn and look forward. |
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Amy Tippins
Member
Username: Amytippins
Post Number: 47
Registered: 06-2009
| | Posted on Saturday, June 04, 2011 - 06:00 pm: |
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Joe, is there any solutions for anyone going off COBRA for personal health insurance? My state has a HIPAA plan, but my prior employer did not elect for prior employees to be able to role into a HIPAA plan. My state supported HIPAA plan is a catastrophy plan as it is, expensive and crappy meds coverage. I could use some direction.
RockScar Love is where we celebrate the scars of new life! www.Rock Scar Love.com
A portion of sales credited to Transplant Buddies goes to COTA! |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 268
Registered: 08-2008
| | Posted on Sunday, June 05, 2011 - 10:37 am: |
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Amy,
There is a federal high risk health insurance plan and several states have a similar plan. My own coverage is through a high risk plan in Illinois. My state plan allowed me to not have a break in coverage because I had 18 months of continuous creditable coverage. (Go here to see the definition of creditable coverage: www.nadp.org/Libraries/HCR_Documents/phsa027.sflb.ashx - Go to Section 2704, Page 9 of the document) Most group health plans that are covered under COBRA qualify as creditable coverage.
The federal plan requires a six month gap in coverage. That would be a big issue for a transplant patient.
Another option is to go to your state and apply for Medicaid coverage. That may not be an option depending on your circumstances - income and dependents.
The coverage, at least in Illinois, is good. Very close to what I had with my prior group coverage and about the same cost as COBRA. I did choose to have a larger deductible with this coverage. That helped to keep the cost a little under what my COBRA was and it has even went down about $100 per month since I got it two years ago. I do not know the benefits or cost of any others.
I was told to start the application process at least 60 days prior to the end of COBRA.
Good luck and keep us posted.
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Amy Tippins
Member
Username: Amytippins
Post Number: 54
Registered: 06-2009
| | Posted on Sunday, June 12, 2011 - 07:59 pm: |
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My state has a high risk plan, but requires 6 months of gap in coverage. I swear they want to kill you off first or break you financially before you can apply for it
RockScar Love is where we celebrate the scars of new life! www.Rock Scar Love.com
A portion of sales credited to Transplant Buddies goes to COTA! |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 270
Registered: 08-2008
| | Posted on Monday, June 13, 2011 - 11:18 am: |
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Amy,
That is not good news. Since both the federal and state require the same gap in coverage, if you choose to go with one of them, it would be interesting to see which one offers the better value.
Thanks for letting us know.
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Deb
Member
Username: Deb
Post Number: 407
Registered: 06-2003
| | Posted on Tuesday, July 05, 2011 - 08:43 pm: |
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So what do you do while waiting on that 6 month gap? Anti-medication is expensive and the insurance will not allow you to get no more than a 30 day supply of medicine per month.
I have been on SSDI for over 8 years and have started putting in job applications and wander beings I am on my husband insurance and Medicare is secondary, what will happen when I get a job if it does not offer insurance? For instance, a part-time job.
Full time positions are hard to find now days. Should I only apply for jobs that offer full-time with benefits?
I would love to work at a non-profit place however, it has no insurance or it is based on funding which can run out. I still have to take anti-rejection meds and type 1 diabetes medication and a few other meds.
Kidney transplant 6/22/2002
lildeb |
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Joe Berry
Forum Leader
Username: Joe910
Post Number: 278
Registered: 08-2008
| | Posted on Thursday, July 07, 2011 - 07:18 pm: |
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Deb,
Most drug companies offer a financial assistance program. I used it once with Astellas. It took very little paperwork and was approved in a few days. A mail order pharmacy sent a 90 day supply shortly after approval. Each drug company has there own set of rules. This is an option for some, but just for meds.
If your husband continues to be insured, you will continue to be covered under his plan as you currently are. After you are working for some period of time, Medicare will no longer be available. If your husband's coverage is sufficient, then you would see little change.
If your husband's insurance is not going to continue, then there are is another option that may be applicable. Each state has a Medicaid program. Their coverage is based upon tow major factors - income and dependents. You could check with them to see if you may qualify for coverage.
Sometimes there are local groups that offer assistance for local residents. Most of these programs are not well advertised. Some are sponsored by church groups.
As you can tell by what I've written so far, there are not a lot of choices. I recently saw a map of the states. A majority of states require the six month wait. I know Illinois is not one of them. In Illinois IF you have had credible coverage for 18 months - like through a group plan at work - there is no wait.
If your husband's insurance is going to continue and the benefits are acceptable, then you do not need to look for a job that has insurance.
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stellatransplant
Member
Username: Stellatransplant
Post Number: 2
Registered: 04-2011
| | Posted on Thursday, July 21, 2011 - 10:40 pm: |
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Hi, Joe ;
1)Hubby had transplant back in April,2011. I am still confused by the coordination of benefit problem.He started dialysis on 02-2008 ( Homo).His medicare start 05-2008. Medicare becomes primary 11-2010.
So basically, His medicare will last for 3 years after transplant (04-2011) and at the same time medicare will be primary payer (04-2011to 04-2014). Right?
2) He has fep bc/bs. BC/BS says it does not coordinate with medicare B prescription drug ( I think it is mainly the antirejection ) medicine). Does this mean I can use bc/bs to get antirejection medicine without using medicare B ? Bc/bs is cheaper since it is $75 for three month supply.
Thank you very much for you thoughts.
have a good weekend! |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 282
Registered: 08-2008
| | Posted on Saturday, July 23, 2011 - 10:31 am: |
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Hi StellaTransplant,
Here are my thoughts, but I would feel much better if you validated my thoughts with Medicare and BC/BS. Medicare benefits from End Stage Renal Disease are not one of my strengths. Since it is a specialized Medicare benefits there are fewer experts, which makes it even more cumbersome and complex than other parts of Medicare.
1. If BC/BS is available, then it will always be primary. Medicare is the payor of last resort and almost all other insurances are primary over them. One exception is Medicaid.
2. My understanding is that if Medicare paid for the transplant, then the transplant meds are paid under Medicare Part A; however, if they were secondary I do not think that this applies and BC/BS will remain primary.
Again, please verify with Medicare and BC/BS. Document who you spoke to and their answer in detail. This is for two reasons. One to verify that I am correct and second to make sure that Medicare and BC/BS are on the same page.
Also, after both agree to who is primary, let each medical provider know at the time of service. Having two payors should make it easier on the patient; however, in many cases it makes things more complex and there are many medical providers who will not know how to correctly bill for services.
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stellatransplant
Member
Username: Stellatransplant
Post Number: 5
Registered: 04-2011
| | Posted on Saturday, July 23, 2011 - 01:27 pm: |
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Hi, Joe
Thanks for the reply. I knew for sure that there is a 30 months coordination of benefit period when You have fep bc/bs. for the first 30 month, bc/bs will be primary and after the 30 month the medicare is teh secondary.
the thing i am not sure is that after medicare became primary after 30 month, then the pateint had a transplant, they will start a new COB period or not, I contact the medicare , the customer sevrice agent alop knows nothing.
thanks |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 283
Registered: 08-2008
| | Posted on Monday, July 25, 2011 - 03:22 pm: |
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Hi StellaTransplant,
Thanks for the info. I did find the 30 month language in my research; however, I did not find anything to indicate another 30 month COB period after transplant.
I would call Medicare again and ask for the next level of support - a supervisor. Their help desk has the beginners answering the telephone. Unfortunately anything other than a "frequently asked question" may stump them. Asking for a supervisor will escalate the inquiry. Most times the supervisor will give you a direct callback number and will follow the question until you have an answer.
Another way is to call BC/BS. They may well know a person at Medicare and they may be able to get the answer.
Most transplant centers have a social worker or a financial counselor that can assist in getting answers. They are able to call Medicare using the provider help desk and many times that help desk is better equipped to get answers.
Sorry I could not help. ESRD is a very specialized Medicare program and as such is very complex. Finding answers will not be easy.
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stellatransplant
Member
Username: Stellatransplant
Post Number: 9
Registered: 04-2011
| | Posted on Monday, July 25, 2011 - 08:11 pm: |
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thank you joe. i really scared of talking with the medicare people. the medicarev should has a special line for esrd. |
Joe Berry
Forum Leader
Username: Joe910
Post Number: 285
Registered: 08-2008
| | Posted on Tuesday, July 26, 2011 - 06:39 am: |
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If you are in the US, you can go to a SHIP (Senior Health Insurance Program) location. You can Google that to find the nearest location. Most of their reps should be willing to help you contact the correct people at Medicare.
Good luck.
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