TECHONOLOGY
His Anesthesia Provider Billed Medicare Late. He Got Sent to Collections for the $3,000 Tab.
Thomas Greene had been experiencing pain in his right leg, a complication from diabetes, when doctors recommended a procedure to increase blood flow to the limb.
Retired from a career as an electrician and HVAC technician, he had an outpatient procedure in April 2021 to alleviate his pain by dilating the clogged artery using a balloon snaked into his blood vessel.
Greene, who lives in Oxford, Pennsylvania, came through the procedure without any problems, and it reduced his discomfort, said his wife, Bluizer Greene. She spoke with KFF Health News on behalf of Greene, who is recovering from other health problems.
Greene is covered by Medicare and a supplemental policy through Humana and did not expect to pay anything for the care, Bluizer said.
Then the bills came.
The Patient: Thomas Greene, 74, who is covered by original Medicare and a Medicare supplement policy sold by Humana.
Medical Service: Peripheral artery bypass surgery on Greene’s right leg.
Service Provider: The operation was performed at Jennersville Hospital in West Grove, Pennsylvania, which closed in December 2021. Anesthesia services were provided by two providers who work for North American Partners in Anesthesia, which is private equity-owned and, with thousands of providers operating in 21 states, identifies itself as among the nation’s largest anesthesia staffing companies.
Total Bill: For the anesthesia care, North American Partners in Anesthesia billed $2,965.58: $1,334.51 for a certified nurse anesthetist and $1,631.07 for an anesthesiologist.
What Gives: North American Partners in Anesthesia, or NAPA, pursued Greene to pay for his anesthesia care instead of billing Medicare on time, sending the debt to collections before the couple discovered the problem.
Medicare eventually received the claims from NAPA, months after the couple started receiving collection letters, Bluizer said. But Medicare denied them because they were filed late — nearly 17 months after the surgery. Humana also denied the claims.
Medicare requires providers to submit claims within a year of providing their services. And Medicare supplemental policies, like Greene’s plan from Humana, generally do not pay for services if Medicare doesn’t cover them, whether because Medicare has not paid its part yet or because the program denied the claim.
A year after Greene’s surgery, in spring 2022, the couple opened a letter from a collection agency working on behalf of the anesthesia group. It demanded Greene pay about $3,000.
“Something has to be wrong, because this is the first time my husband has ever been asked to pay out-of-pocket and we’ve had the same insurance for years,” Bluizer said.
She said for several months she called NAPA and the collection agency, C.tech Collections, of Mount Sinai, New York, to determine why it was billing her husband.
Greene was also contacted by the Faloni Law Group, a second organization working on behalf of NAPA to collect the debt, and Bluizer said she followed its instructions to respond by mail, disputing the debt on the grounds that it should be billed to insurance.
But her communication attempts did not resolve the issue, and she said her husband continued to receive collection notices.
Neither debt collector responded to requests for comment.
“We were angry, and it was very upsetting because we had never had a bill put into a collection agency for any of his hospitalizations, and it was money we did not feel that we owed,” Bluizer said.
She said they may have received some letters from the anesthesia group in 2021 and 2022 that they discarded without opening because they believed her husband’s medical bills would be covered by insurance, as the rest of his surgery bills were.
Worried about the situation, including its potential impact on their credit, the couple reached out late last year to Harold Ting, a volunteer counselor for Pennsylvania’s MEDI program, which provides free assistance to Medicare beneficiaries. Medicare generally covers anesthesia services.
“This is totally unfair that a beneficiary ends up having to pay for what should be a totally covered service, when the provider is at fault,” Ting said.
Two explanation of benefits statements from Humana show the insurer received claims from NAPA in April 2021, shortly after Greene’s surgery. The statements said the claims could not be considered at that time, though, because Humana had not yet received Medicare EOBs for the services.
Kelli LeGaspi, a Humana spokesperson, declined to comment on Greene’s case. She said a Medicare EOB — a coverage statement generated when the program processes a claim — is required for the supplement carrier to consider a claim. Without it, a claim for secondary coverage cannot be considered and is denied, she said.
Supplement plans deny claims for benefits that are denied by Medicare, she said.
“If Original Medicare declines to pay the claim, then the Medicare supplement plan is required to decline the claim as well,” she said in an email.
In December 2022, a NAPA representative told Bluizer in an email that NAPA billed Medicare after the April 2021 surgery and that Medicare denied the claims in August 2021. The representative provided an account statement showing the claims were sent to collections that month.
But Bluizer said a Medicare representative told her in late 2021 that the program had received no claims from NAPA.
Greene’s Medicare account shows NAPA filed claims in September 2022, about 17 months after his surgery and about five months after he received his first collection letter. Both claims were denied.
A quarterly summary notice said while the time limit for filing the claims had expired, Greene also could not be billed.
Meena Seshamani, director of the federal Center for Medicare, said in an email to KFF Health News that if a Medicare provider sends a claim a year or more after a service is provided, it is denied except in very rare circumstances.
There is no exception for provider error, she said.
A spokesperson for NAPA declined to be interviewed on the record, despite receiving a signed release waiving federal privacy protections.
Martine G. Brousse, a billing expert and founder of the patient advocacy firm AdviMedPRO, said Greene’s Medicare notice should have reassured the couple that he did not owe anything, despite the several overdue-bill notices they received.
If the Medicare statement “shows a zero balance to the member, then the provider cannot legally go after the patient,” said Brousse, who is not involved in Greene’s case. “The patient has zero liability because it is not their fault” the provider billed Medicare a year after the surgery. “That is the end of the story.”
Another mystery about the claim is why NAPA billed separately for a nurse anesthetist and an anesthesiologist. Bluizer said her husband was not told why NAPA billed individually for the two medical professionals — a practice some insurers believe constitutes double billing.
Brousse said there could be a simple explanation, such as if the nurse anesthetist started the procedure and the anesthesiologist finished it or if the company charged for the anesthesiologist to work in a supervisory role.
But the Medicare claims document shows each provider billed for the same amount of time — a little over an hour.
“As far as I can tell, this looks like two providers billed with the same ‘I did the job’ Medicare procedure code,” she said. “Medicare cannot accept that without an explanation.”
The Resolution: Unable to get answers, Ting connected Greene to the nonprofit, Pennsylvania-based Center for Advocacy for the Rights and Interests of Elders.
In March, Ariel Rabinovic, an advocate with the center, contacted NAPA on Greene’s behalf and explained that federal law does not allow the group to bill Medicare patients for services Medicare does not cover. He said he was told the company would stop billing Greene.
Bluizer said the couple has not received any collection notices since then.
Rabinovic said he has seen other situations in which health providers who agree to accept Medicare try to bill patients for services Medicare does not cover, which is not allowed.
“Older folks have a lot of things going on, and dealing with this can be very confusing for them,” he said. “A lot of people end up paying because they don’t want to deal with it.”
Greene has faced several health issues and spent time in a rehabilitation hospital this winter. His wife said she was happy the billing issue had been resolved without their having to pay anything.
The Takeaway: When a Medicare statement says the patient may not be billed anything for a health service, that’s the bottom line. Don’t write a check, but also don’t ignore bills and collection notices, because they could ultimately hurt your credit.
Read your mail, the experts said. While Greene was not responsible for paying the anesthesia bill given that Medicare said he did not owe anything, the couple may have prevented the debt from being sent to collections if they had responded to the anesthesia group’s communications and confirmed it had Greene’s insurance information, Brousse said.
Keep copies of bills and insurance statements, especially Medicare EOB documents, or follow them on an online portal.
The couple was smart to reach out to advocates for help resolving the issue when they could not do so on their own, Rabinovic said.
“This is why people need to read their notices from Medicare even when it says ‘This is not a bill,’” he said.
Also, when an anesthesia bill includes charges for both a nurse anesthetist and an anesthesiologist, question the charges. Many insurers will not pay for both.
The Centers for Medicare & Medicaid Services recommend beneficiaries call 800-MEDICARE with questions about their care or bills or file a complaint online.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
#Anesthesia #Provider #Billed #Medicare #Late #Collections #Tab
In the world of Medicare, there exists a peculiar term called the “donut hole.” No, we are not referring to the sweet, deep-fried confectionery that tempts our taste buds. Instead, the doughnut hole refers to a unique coverage gap in the Medicare Part D drug plan (Medicare’s prescription drug program). Understanding this concept is essential for those relying on Medicare for their healthcare needs. That’s because it directly impacts out-of-pocket expenses for prescription medications.
Medicare Part D Donut Hole
The donut hole is a phase within your Medicare Part DD prescription drug coverage (It is not related to medications that are covered under your Medicare Part B). It is where beneficiaries must bear a more significant portion of their prescription costs. It is a point in your drug coverage, marked by a specific dollar amount. Once you spend a certain amount on medications and reach a certain threshold, beneficiaries enter the “donut-hole”. This is where they are responsible for a higher percentage of costs until they reach the next threshold.
Though the concept may appear confusing at first. Being aware of it is paramount for beneficiaries to effectively manage their healthcare costs. It will also help them make informed decisions regarding drug coverage. Let’s dive a little deeper into the specifics and how it affects beneficiaries.
When do you enter the donut hole?
The donut hole begins once the total amount spent on covered drugs by both the person and their insurance plan reaches a certain threshold. At this point, the individual enters the initial coverage stage. In other words, you’re in the donut hole. This is where you’re responsible for paying 25% of the cost for brand-name drugs and 25% of the cost for generic drugs (the drug manufacturer pays 75%).
It is important to note that the cost that applies towards reaching the threshold includes the following: The amount paid by the person and any drug manufacturer discounts received for brand-name drugs.
Once the individual reaches the catastrophic coverage threshold, their out-of-pocket costs decrease significantly. It is crucial for individuals enrolled in Medicare drug plans to be aware of this and plan their medication expenses accordingly.
When do you get out of the donut hole?
Once you exceed the threshold of cost, you will be out of the “donut-hole” and you’ll enter the catastrophic coverage phase. When closing the donut-hole, it’s important to note that not all expenses count towards reaching the threshold.
For example, Part D premiums don’t help you with this coverage phase. Payments made by your drug plan and manufacturer discounts are among the costs that don’t contribute to reaching the out-of-pocket limit.
How to avoid the Medicare donut hole?
Navigating the complex landscape of Medicare can be overwhelming. However, there are strategies to help minimize the impact. One approach is to carefully select a Medicare Part D coverage plan and review its costs. Comparing different Medicare plans and understanding their formulary can allow beneficiaries to determine which plan provides the most comprehensive Medicare Part D coverage for their specific medication needs.
Another way to avoid the donut-hole is to take advantage of cost-saving initiatives, such as generic drugs or mail-order pharmacy services. By opting for lower-cost alternatives and prescription delivery services, beneficiaries can stretch their medication budget. This can potentially delay reaching the threshold. It is also crucial for individuals to monitor their medication usage throughout the year and be aware of their total costs. Tracking expenses and consulting with a Medicare expert can ensure beneficiaries stay informed. It helps to take these necessary steps to avoid falling into the Medicare donut-hole.
When is the Medicare Donut Hole Closed?
In the past, beneficiaries had to cover the full cost of their medications while in the gap. However, with the passing of the Affordable Care Act in 2010, a plan was put into motion to close this gap in coverage completely. This plan aims to reduce the out-of-pocket costs for beneficiaries during the Medicare prescription drug coverage gap.
The closure is being phased in over several years, with incremental improvements each year. In the coming years, it is expected that it will be completely closed. This means that beneficiaries will no longer have to pay the higher percentage of their covered prescription drug costs out-of-pocket while in the gap. Instead, they will pay a lower percentage, making their medications more affordable and accessible.
Will the Prescription Drug Part D Coverage Gap Go Away?
The future of the Part D prescription drug plan gap is a popular topic. Originally, the gap was implemented as a cost-saving measure and was intended to encourage individuals to use generic drugs, thus reducing overall healthcare expenditures. However, over the years, this has proven to be a burden for many Medicare beneficiaries, who face significant out-of-pocket costs when they fall into this gap. As a result, there have been ongoing discussions about the need to eliminate or modify this coverage gap stage.
The good news for 2023 is that the coverage gap phase is set to be fully eliminated in 2025. This means that Part D enrollees will no longer face heightened costs during this phase. Instead, they will continue to pay their regular cost-sharing amounts for prescription drugs throughout the year.
The elimination of the Medicare coverage gap phase is a significant improvement for beneficiaries. It removes a financial burden that many have faced in the past and aligns with the goal of providing more affordable access to necessary medications. Click here to learn more about Medicare Part D plans.
How does donut hole work with Medicare Advantage & Medicare Part D costs?
The donut-hole is also connected to Medicare Advantage plans that have a Part drug plan. These plans are also known as MAPD plans or Part-C.
MAPD plans, which are private insurance plans that provide Medicare benefits, often include Part DD plan drug coverage as part of their offerings. Therefore, it can also apply to those enrolled in MAPD plans. Since these plans often include drug coverage as part of their offerings, the coverage gap commonly can also apply to those enrolled in these plans. Click here to learn more about the Medicare Part-C program.
Conclusion
Out-of-pocket drug costs can take a toll on your wallet. Whether you have a Medicare Supplement insurance plan or an MAPD plan, your annual drug costs can be significant. Even if you don’t take any medications today, you should still get a Part-D plan to avoid a penalty. However, if you take medications and fill a prescription, your Part-DD plan should keep your overall costs lower compared to not having one.
It’s understandable if all of this is overwhelming. That’s why we created an easy to learn course to get you familiar with the Medicare system. People with Medicare rave about our free course. The free course provides additional information about the different parts of Medicare, enrollment, costs, what Medicare pays and what it won’t and more.
The suit complained Google intentionally sent RNC political emails to Gmail users’ spam folders, and the RNC sought restitution for “donations it allegedly lost as a result” of those lost emails. The RNC cited a North Carolina State University study that found Gmail was more likely to mark emails from Republican campaigns as spam. One of the study’s authors spoke to the Post in May last year, saying its findings had been misrepresented. Muhammad Shahzad noted that it only tested default email settings — in tests on accounts where users indicated their preferences by marking some messages as spam, “the biases in Gmail almost disappeared.”
While US District Court Judge Daniel Calabretta described the RNC’s suit as a “close case,” he dismissed the Committee’s claims, writing that it had “failed to plausibly allege its claims” that Google’s filtering was done in bad faith. Google claimed that many of the filtered emails were likely picked up by its spam algorithms because of user complaints and pointed to problems with the RNC’s domain authentication and frequent emails as other culprits.
The judge also said Republican emails could be considered “objectionable” content based on the definition in the CAN-SPAM Act and said that Google designating them spam is protected by section 230 of the Communications Decency Act. The decision left Republicans with partial “leave to amend to establish a lack of good faith” on Google’s part.
#Judge #dismisses #Republican #lawsuit #Google #Gmails #spam #filtering
Are you ready to take charge of your healthcare like never before? In 2023 insurance carriers are rolling out an online price transparency tool available for 500 shoppable items and services. In compliance with Transparency in Coverage, subsequently implemented under the Affordable Care Act (ACA) of 2020.
Say goodbye to the days of uncertainty and hidden fees! With this tool, you’ll clearly understand what to expect, allowing you to plan and budget for your healthcare like a pro.
It’s a game-changer! You are finally able to inform yourself about the cost of that medical procedure you’ve been considering. Curious about the price of a specific service? An internet-based price comparison tool that allows an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider. You can even request the same information over the phone by calling your insurance membership line.
We can’t stress enough how important it is for you to sign up with your provider’s member portal. It will help you to maximize your coverage and will provide you the power to manage your account seamlessly. In addition to accessing your explanation of the benefits of your past procedures, you will see how much you have paid towards the deductible and out-of-pocket maximum, you will be able to locate providers and hospitals in your network, be able to see your policy payment status, pay your premium online and also now be able to find the treatment cost estimator.
Blue Shield of California
Treatment Cost Estimator is a new tool already available for Blue Shield members. This calculates the overall cost and out-of-pocket expenses for frequent in-network medical procedures. Moreover, projections offer the members of transparency and clarity they need to budget and make future healthcare plans. Click 👇 here to view Blue Shield treatment cost estimator brochure.
Kaiser
Here’s for Kaiser members. Log in to your member portal, then click on the “benefits” tab. Scroll down, and subsequently, you will find the “Find cost estimates” section. The list of procedures is clickable therefore you can click on each to see their estimates.
Anthem
Anthem members should go and log on to anthem.com/ca. Once the member logs on, they will click on “Care” at the top of the site; lastly, they will need to “Shop for Procedure”. You should be able to find the information you need.
LA Care
With LA Care’s utmost security over the phone, each member is welcome to call member services at 855-270-2327 to walk you through navigating the portal.
Oscar
To make the most of your membership benefits, don’t forget to log in to your personalized Member Portal at https://www.hioscar.com/auth/login. It’s your gateway to a world of convenience and control over your insurance needs.
In addition, you have access to a dedicated Concierge team ready to assist you with any insurance-related inquiries. Simply give them a call at 855-672-2755 (opt#2), and they’ll be more than happy to walk you through this feature.
You can also contact your Care Team through direct messaging at [email protected]. Remember to include your OSC# and provide all the details to ensure a swift and accurate response.
Utilizing these cost estimation tools can save time and effort in understanding your health coverage costs. You will no longer have to spend hours poring over complicated insurance documents or making numerous phone calls to your insurance provider. Instead, you can access all the information you need at your fingertips and make informed decisions about your healthcare.
If you would like to discuss your health insurance options with a personal touch, feel free to reach out to us at 310-909-6135 or send us an email at [email protected]. We are here to provide dedicated assistance in safeguarding your future and protecting your loved ones today.
#Transparency #Coverage #price #information #accessible #public
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