An elderly friend recently had to go to emergency with severe pain and was told that any tests run may not be covered for her. When she received the bill, it was around $15,000!! She has good insurance and also Medicare, so we wonder if the Affordable Care Act has reduced coverage for people over a certain age?
All too frequently, the problem is with the coding done by the hospital, so she should should start with her insurance company and ask how to go about seeing if the hospital coding is correct.
I might add that people on Medicare often get statements from the insurance company that reflect the cost before their supplemental plan is considered. It can be horrifying. So, please have her call. She may not owe as much as she thinks.
About the fact that they didn't know if something is covered - that's scary for people. It's not the Affordable Care Act - this has been the case for years. If something isn't covered by Medicare, then it's not covered by the supplemental insurance either. And the costs - as you saw - can be incredible.I hope this isn't the case with your friend.
Warm regards,
Carol
And most of the Affordable Care Act doesn't take effect until 2014. So I don't think that's what's changed, if anything has.
Carol
I would assume that it's a screw-up with the insurance. Please let us know how this works out.
There are some tests and physical therapy that use to be covered by Medicare but it is no longer covered or has been reduced. When something like this happens the patient is suppose to be informed and they even have you sign a form stating that you realize Medicare may not cover whatever it is. If you sign it and they do it, you are saying that you agree to pay for said services. The thing is you keep saying she has "really good insurance and Medicare." That statement worries me as normally Medicare is the primary insurance, if you are no longer working. When I hear patients say things like this I get sick to my stomach as it normally means they belong to an HMO and have signed their Medicare benefits over to the HMO. When this happens, you no longer actually have Medicare, you now have an HMO, like Kaiser, Humana, Scan, etc. YOU MUST SEEK ALL CARE THROUGH THEM AND THEIR DOCTORS AND HOSPITALS, MUST, MUST, MUST!!!!!!! If you fail to do this you will be responsible for paying all charges because you did not seek care through a participating provider!!!!!!!!
Lastly NEVER PAY A BILL LIKE THIS!!!!!! UNTIL YOU HAVE CHECKED OUT WHY IT WAS NOT PAID AND IS IT BEING SUBMITTED TO A SECONDARY INSURANCE CARRIER!!!!! IF YOU PAY ANY AMOUNT OF MONEY TO A DOCTOR OR HOSPITAL, MANY OF THEM DO NOT REIMBURSE YOU AUTOMATICALLY....UNLESS YOU ASK THEM TO!!!!!!
This ticks me off to no end, but I have worked for them and let me tell you they will hold on to the money because they can. There is no law that states that they have to pay you back within any amount of time. I think this is wrong, wrong, wrong and they should be penalized for doing it, but when they see they have $100,000 sitting in their bank account that should be refunded, they don't want to and they will hold on to your money!!!!!!!! My former employer is currently sitting on a large sum of money that he refuses to refund of his own accord and has instructed his bookkeeping office to hold on to the funds unless the patient requests a refund. Most of these patients are elderly and do not even realize they have a refund coming. It is sickening!!! DO NOT PAY ANY PHYSICIAN OR HOSPITAL UNTIL YOU HAVE EXHAUSTED ALL AVENUES OF PAYMENT TO THEM. DO NOT GO OUTSIDE YOUR HMO EITHER!!!
There is a problem in some places with doctors accepting patients with Medicare so you have to ask every doctor you see if they will accept Medicare, many are taking new patients due to reimbursements.
It's complicated. I don't want Medicare to make ME pay more for my care, but I want them to cut out all the fraud and abuse from "the bad guys." I want Medicare to be available to me and my daughter, and they need to reduce the costs to ensure that. Rock and a hard place.
As others have said, she needs to take the time to carefully review the statement to see what it is and what is expected. Almost all facilities take Medicare and Medicare reimbursement rates are set and paid the same for the specific coded procedure. Now the issue will be with the non-Medicare paid for part of her costs. If it was an out-of-region or none-participating provider, the costs could be significant. This is the same thing if you go to see a doctor or go to a clinic or hospital who is not in your health insurance groups "network". (BTW This is one of the reasons why the ACA is so very important in that for regular health insurance the out of region f***ing you get will be gone.)
The statements can be mailed with 48 hours from discharge or when a procedure was done and usually the first mailing does not include any payments from Medicare or the insurance company. So the amount will be some kinda huge. Then maybe 30 days later you get another statement that shows the anticipated insurance payment and then 60 days later another statement with credits, etc. Once Medicare has paid their negotiated rate and you get billed the balance due. If they are in-network it will be reduced and if not in network it won't be. Then there are charges that neither Medicare or insurance will pay ever.
It is not just the elderly that have these costs. You know I think that about 50% of all bankruptcy's are due to medical bills. One health problem & hospitalization can easily run 6 figures, and there are really no more Hill Burton funded hospitals out there like there used to be to provide for free care. Gosh, even C sections can run 20K. I just had a CAT scan due to 4th nerve issue and the study was 5K. Our insurance paid 80% and the rest had to be paid or debt contract signed before the procedure was done - if we did cash or debit card they took 20% off. Not everybody has 800K in their purse right now and that was just for 1 test. Now the digital imaging center closest to us, was NOT in network and if I went there then our insurance would only pay 50% of the cost. So I had to make sure they were in network even though the procedure was the same. It was up to me to find that out. ACA should limit that happening in the future.
But if they are just on observation, then it's like being in the doc's office and so lots of lab tests, x-rays, scans, etc as there is no set limit to what can be billed. I bet a lot of the test done get run through outside vendors too. Probably some Stark Law violations in all that too. I would so like to see CMS go in heavy on Stark compliance with doc's and their lab agreements.
I've been shocked at some of my own medical statements, until I notice they have not been submitted to insurance yet ... or they have submitted it but not received payment yet. Whew! When all was said and done, I didn't owe anything, or perhaps a $10 copay.
I don't know what the $15,000 charge means for your mother. I sincerely hope it turns out she owes much less than that. Please let us know. We learn from each other.
You're obviously a very caring person and if she's worried about paying $15k, I think she'd be thrilled at the idea she might get some of that back. Let us know if you do pursue it with her.
This was the first time this ever happened to us or that Mom was held solely for "observation" so it threw me. I do not understand why she would have ever been put into "observation" when a doctor told them she needed surgery immediately anyway!
Some of these brand new doctors that are in these HMO's scare me as I wonder just how good they really are since they do such stupid things. I feel like they cannot be trusted. Mom's private doctor retired and sold his practice to an HMO is how we became involved with these doctors anyway, now we have to find a new private practice doctor for her to see.
When the hospital sent me a questionnaire about Mom's stay, I did complain and told them what all had gone on and this doctor that was just going to release Mom and let her live with gall stone pain.
We have received some statements in the mail but everything has been covered. I was waiting for a bill to come in and getting ready to raise heck over it.... so far it has been good. Could use suggestions for finding a good private doctor for her for the future.
When my mom was to have a heart procedure, the cardiologist in the practice was arrogant and ignorant of the medications he gave my mom to prep for the procedure. So I asked around and took her to another doc in that practice, who we love. You can also look online at some of the ratings websites, but I think those aren't as helpful as nurses. They know what's really going on. If you need a cardiologist, then go to the hospital's heart floor, etc. Finding the right doc can make all of the difference in the world for your mom. Good luck!!