Medicare denial, any suggestions?

Well, Medicare has been denying payment for parts of my bariatric lab requirements.  They also denied part of my sleep apnea machine which they had been covering.  There is just one final payment and then the medical supply company said the machine would be mine. I  found this out by going online and looking at my claims thing.  I had not been notified of any denials so I am really confused. 

I called today and spoke with a  Medicare rep who was not unkind, just not very helpful. In fact, she gave me misinformation so that when I called the Lab company and told them what she said, they said that she was wrong blah blah.  Oh me. 

Goodness, is anyone familiar with navigating these waters and how do I convince them to pay for my Bariatric ordered labs?  I have a secondary insurance but it requires Medicare to pay and then they pay either all or a percent of what is left. 

What a mess!  And it is getting to be expensive.  We had to pay over $400 for the tests back in Oct and then I saw they denied the January tests.  I have some upcoming tests but I am so hesitant to have them done as we like most others are pretty strapped at this time so the idea of paying that much for each set of labs seems daunting. 

Any help, suggestions would be appreciated.  Just do not know where to start even.  

 

The only thing i can think of is, what code did the doc's office use with the labs?  Maybe if it was coded differently they might pay for it?

Hmm, good point, Kelly!  I will talk with them and see if they coded it correctly!  

I had a code issue also and once the doctors office was made aware they recoded, resubmitted and it was paid. I also know Medicare will only pay for certain things at specific intervals and labs are one of those items. For instance my parents are on Medicare and they can only see the pcp at 3 month intervals unless there is a specific issue. The pcp does a check every 3 months and it is covered but for them to go in the interim there has to be illness like UTI or a cold etc. Labs can only be done the same way. Retesting blood work is covered at specific intervals. You might be doing blood work too often. Just a thought. Your doc should know about this though. Theirs always cautions that it will be self pay. My dad is a prostate watching fanatic and always wants his blood work checked constantly. Well he can't do that unless he pays out of pocket. But the doc tells him that. Anyway just an idea. I don't think Medicare has ever denied them on anything other than doing something too frequently. They have used it for 30 years as they are in the late 90's.

Hmm, thank you.  I am only getting the labs as required by my surgeon post op.  At 2 weeks, at 6 months and then not until 1 year.  That is really good info on the pcp only be allowed every 3 months.  But I do not run to the doc for every thing so dunno.  Appreciate the input.  Good on your folks being in their 90's wow.  You are so blessed.  I sure miss my mom and dad.  Still feel like an orphan, LOL.  

Medicare has strict guidelines on what they will cover.  If its not on their approved list within the approved timeframes it will not be covered.  It will probably  get worse in the future.  One suggestion would be to talk to the lab before you have the test done and see if you can arrange a cash discount.  Try to get a discount equal to an insurance discount.  In some cases insurance is paying about 20% of the total amount billed. If medicare/insurance doesn't cover it they can charge you the full amount they billed out. It is the cash customers that are making the labs profitable. Once the insurance has been billed they are unlikely to work with you. A cash discount needs to be arranged upfront.  The only good news is that you know which lab tests medicare doesn't cover and use that when working with the lab for an upfront discount.

 

I agree that it will likely get much worse.  That is a great tip tho, about the labs so I will try that.