Government

The fun you can have dealing with Medicare. Have you ever filed a claim?

There is a movement to add a public option to the ACA, in fact that proposal is included in the Democratic 2016 platform.  The idea is that somehow government is more efficient than the private sector and that profit is the driver of health insurance premiums. Of course, neither is true.

About Medicare; the majority of time claims go through uninterrupted which is the same with private insurance, the vast majority of claims go through without issue.  In fact, claims processed by Medicare are processed too quickly and too automatically; ask your doctor.  That is another story though.

Recently my wife saw a doctor who does not participate with Medicare and who would not file a claim for her. After a bit of investigation I found a claim form on-line and filed the single office visit claim on her behalf. That was on May 5th.

On May 20th we received a form letter telling us our claim was being processed, but it could not be completed without additional information. They wanted to know if (1) was the claim being submitted for denial only? And (2) does your physician refuse to submit the service to Medicare (also noting that by law all physician providing services to Medicare patients are required to file claims with Medicare). Which begs the question of why there are any claim forms in the first place. 😜

After going back and forth with the physician, we finally returned the form on June 7.  This was after his office called Medicare and was instructed to tell us just to check the correct boxes and return the form as requested.

On July 14th we image received a claim denial from Medicare.  The reasons were A) Your provider must complete and submit your claim and B) The information we requested was not received.  Recall that we were instructed to return the completed form as was the doctor which we did. In addition, neither my wife nor the doctor received a request for any information beyond the form letter.

As an aside, my wife was a health insurance claim processor for many years and later was an office manager for a physician. I spent nearly fifty years managing health benefits for a large employer so in theory we know what we are doing; that is until we deal with government.

I’ll take care of this I said with confidence, I’ll call Medicare and I did.

My wait to speak with an agent was fifteen minutes.  When I did reach someone, I spent another fifteen minutes going over the whole story I related above and answering an array of questions.  After the fifteen minutes the agent told me it was a claim problem (duh!) and she transferred me to the claim department.  Progress at last!

That agent was nice, but talked to me like I was senile and kept telling me I was confused … That did not sit well with me.  I was not confused and I’m not confused now.  

Okay, I went through the entire story again, she asked questions, she checked her computer whereupon she told me the claim had been denied. I KNOW THAT! I said, that’s what I told you, the question is why and what information do you want and who did you ask for the information? The agent finally told me she had gone as far as she could and could not give me any more information.  Say what?

imageHere is the good part. She suggested I write a letter to the people who process claims and who denied the claim. Aren’t I talking to the claim department I asked. She told me no; that was a contractor.  Who do you work for I asked, another contractor I was told. You don’t have access to their system to answer question I asked? Sorry, no she said, you will have to send them a letter appealing the denial.

I will just call them, I said.  You can’t call them, they don’t take phone calls from beneficiaries I was told.  The third-party who processes claims in my area is an organization called Novitas Solutions, Inc [1] and does not talk to Medicare beneficiaries about their claims and the people who do, do not have access to the system that is used to pay or deny claims. Novitas does, however, have a robust website and they talk with physicians, just not the people they process claims for.

So now it is July 29 and I am back to square one. The doctor is now trying to figure out how to process a Medicare claim which he has never done. The doctor has his $250 and the patient is left hanging by the system, a system that won’t talk to its customers.

This is the system that is claimed to be more efficient and less costly than the private sector, this is the system politicians want to add to the ACA and to allow Americans age 55 and over to voluntarily join.

[1] Novitas Solutions is a subsidiary of a subsidiary of the holding company for Florida Blue Cross. The very entities we love to hate (insurance companies) are the same people processing claims for a system we are told is better and more efficient.  In all fairness to Novitas, they operate under rules established by the federal government.  That should give you are warm and fuzzy feeling.

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