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Medicare and Health Care


*This is a non-medical board. This site shall not be used to seek professional, medical or legal consultation.

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age person with End-Stage Renal Disease (ESRD). There are many different parts to Medicare; with all of these options, it can be confusing.

This forum will allow members to share their experience with medicare and seek advice* on certain medicare-related situations.

To read today's top news stories on federal employee pay, benefits, retirement, job rights and other workplace issues visit FederalDaily.com.

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freeageless  
#1 Posted : Friday, December 11, 2009 10:50:08 AM(UTC)
freeageless

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If you want to go to a doctor who does not accept Medicare patients, can you just tell the bookeeper if he or she asks that you do not have Medicare even if you do have it. Then can you just go ahead after you see the doctor, pay them yourself, and then submit the bill along with the Medicare form, and possibly see some reimbursement from Medicare, and some from your secondary carrier, which in my case happens to be Blue Cross Standard. Medicare is primary for me, since I am retired.
Kathi52  
#2 Posted : Friday, December 11, 2009 10:57:18 PM(UTC)
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Freeageless,
 
I am no expert on this but I will say I certainly wouldn't advise it.  If you notice in your BC/BS booklet it will say that you MUST notify them you have Medicare...meaning BC/BS of course.  There's a reason for that and I highly, highly doubt you would be reimbursed.  Having said that though, and again I am no expert, I do have somewhat of a similar question.  If a particular doc doesn't accept Medicare but does accept BC/BS can we use our secondary which is my case as well?  I don't know maybe we are asking the same thing...but it is early in the morning and I might not be making much sense. Smile
freeageless  
#3 Posted : Saturday, December 12, 2009 1:35:15 AM(UTC)
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I think our question is very similiar. Blue Cross knows I have Medicare. Normally what Medicare does not pay, Blue Cross pays. However, there are some doctors like you said who do not take Medicare patients, but who do take Blue Cross. I know that we have to notify Blue Cross if we have Medicare. My question is do we have to notify the doctor or his bookeeper that we have Medicare. Can't we just file the claim with Medicare ourselves, pay the doctor upfront, and then see if Medicare will pay and if the doctor (as in my case) takes no insurance, see what Blue Cross will pay? In your case, can't you just not tell the doctor, that you don't have Medicare, and see what Blue Cross does? I am guessing that Blue Cross will tell you, that you have to file the claim yourself with Medicare, and if Medicare denies it then Blue Cross will pay what they normally would pay for the claim. However, I don't know that is why I am asking the question. I know that doctors are supposed to file the claim with Medicare, but I also notice that on Medicare's website there is a form that you can fill out to file the claim yourself if the doctor refuses to do it. My question is it legal to tell the doctor's staff you do not have Medicare or not mention it to them at all? I know that we have to tell Blue Cross that we have Medicare.freeageless2009-12-12 09:43:22
kg78  
#4 Posted : Monday, December 14, 2009 10:41:25 PM(UTC)
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part of the reason doctors don't like medicare is because they insist on paying lower rates than normal insurance does.  When you have medicare plus a secondary insurance, medicare still insists that the docs charge the medicare rate.  Your doctor can't charge you the normal rate he charges, have medicare pay their portion and have BC/BS pay the rest.  By law, if you have medicare coverage and they accept you as a patient, they HAVE to charge the medicare rate.  That's why you can't choose not to tell them and then submit to medicare for reimbursement.  The rates they charge have to be different from the outset.
dogmom  
#5 Posted : Tuesday, December 15, 2009 7:19:53 AM(UTC)
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Gee, I really can't wait till I'm eligible for Medicare.  NOT!  Heck, I'm having enough trouble finding a doctor who will take new patients WITH good insurance - the system is sooooo broken!
suezeekay  
#6 Posted : Friday, January 01, 2010 11:16:50 PM(UTC)
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http://www.bloomberg.com/apps/news?pid=20601087&sid=aHoYSI84VdL0
Mayo won't take Medicare anymore at this clinic in Arizona.
 
Isn't there some law that if you are over 65, on Medicare or not, that the doctor can only charge you 110%of what Medicare reimburses?  I have BC and I didn't sign up for part B so I'm only constrained by the Part A hospital coverage as far as I know.
Mark the Mailman  
#7 Posted : Saturday, January 02, 2010 9:47:12 AM(UTC)
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I think how this will all work out is that BC becomes your primary in this case....
Let them advise you on any claims you need to send to Medicare, or if they will do that for you.
 
I know I definitely would be finding another Dr. after this experience.
If that is not an option for you, at least keep us posted on this thread
how it worked out for you.......Interesting
OUtside  
#8 Posted : Saturday, January 02, 2010 11:10:16 AM(UTC)
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Here’s my view of this. The rule you are referring to is the fehb law, it says that whether or not you have Medicare, a doctor who does not take Medicare cannot charge you more than 115% of the Medicare rate. BC will obtain the Medicare rate for you and should then advise you what your co-pay will be, it probably will be your usual co-pay under BC plus the 15% (assuming the additional 15% is approved). Read page 23 of the BC brochure to understand this point better with respect to both BC Standard and Basic and to have an idea of the of the different variations, for example, doctor does not take Medicare but does take BC or doctor takes neither Medicare nor BC.

Note that because the Medicare rate is usually lower, some doctors will not see retirees 65+, but you can hope that if he/she takes BC, they would see you on that basis.

The person who started this thread asked whether it would be correct to deny having Medicare to the doctor if retiree has it. I have wondered the same thing but there is the concern of giving invalid information. Also, if the point is the doctor, not realizing retiree has Medicare, would be able to charge more than the Medicare rate, he can only charge 15% more than that rate as per that law mentioned above. Note that Medicare has the same rule, for people who have Medicare, it is discussed on page 47 of the Medicare booklet.

Finally, when reading back over your post about being constrained only by Part A, I hope you see that, in effect, the Medicare rate, as would be imposed by the fehb rule, also constrains the fehb subscriber who does not have Part B. When one thinks about that for it while, it is a reasonable constraint because otherwise federal retirees could be paying differing amounts for doctor visits, one amount for those who have Part B and another for those who don’t. It makes sense there should be no difference, one reason, ISTM, is that premiums would have to increase for everyone in the program to cover the group with the higher doctor visit rates.

mallen  
#9 Posted : Monday, January 04, 2010 2:06:33 PM(UTC)
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Actually,there is one other issue. BCBS will NOT pay more than they are legally obligated. If a doctor wont take medicare,but is still required to only bill the medicare rate,then BCBS will only pay that medicare rate. They will deny anything over that,as they are not required to pay it. In essense,you have tricked a doctor into being able to charge only that medicare rate. Thats not going to go over well. At the very least,your only going to be seen once. Im not sure if there is anything else they can do about it though.
freeageless  
#10 Posted : Monday, January 04, 2010 11:49:18 PM(UTC)
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Mallen, Keep in mind that that is true only if it is a Medicare covered item. There are a lot of things that are not covered by Medicare. In that case, Blue Cross reimburses, in my experience, very well.
OUtside  
#11 Posted : Tuesday, January 05, 2010 1:13:21 AM(UTC)
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mallen, you’re making a very interesting point but I don’t think I would agree with it because we already know that some doctors will not see retirees aged 65+ due to the low Medicare rates. And the vast majority of retirees are subject to these rates, eg, private industry retirees who have Part B, fed retirees who have Part B, and fed retirees who decline Part B. That covers the majority of retirees, therefore, since most, if not all, of his age 65+ patients are paying the Medicare rate, doctor should not be too surprised if another age 65+ patient pays this rate, too.

In addition, if doctor is a PPO to suezeekay’s BC mentioned in her post, do you think he would not see her again because he refuses the rate established by BC (which happens to be the Medicare rate)? Your guess is as good as mine but I think probably no given his status as PPO.

But I think suezeekay’s suggestion of constraint imposed by the Medicare rate on someone who declines Part B is best looked at differently. Even when a retiree declines Part B, she is protected from a high doctor bill because the doctor cannot charge her more than 15% of the Medicare rate. It seems to me this is a privilege rather than a constraint, although I realize she seems concerned about doctors not accepting Medicare and perhaps not accepting her because of her age. Still, consider what she could be charged by doctors if the rules were different.

jeserf  
#12 Posted : Tuesday, January 05, 2010 1:44:12 AM(UTC)
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dogmom wrote:
Gee, I really can't wait till I'm eligible for Medicare.  NOT!  Heck, I'm having enough trouble finding a doctor who will take new patients WITH good insurance - the system is sooooo broken!
 
Find a doctor that doesn't take any insurance and negotiate the cost of your care.  Your tests and other generally expensive items will still be covered, but your visit/exam will not be.
 
My doctor doesn't take any insurance - I tell her what I can afford and that's what I pay.  anything that gets done there from a hearing test to blood work gets covered to some degree by my crappy insurance.  The only program/insurance she takes is Medicare.  I refuse to have to find a new doctor since I love mine and am comfortable with her.  i'd rather have good care I trust vs. care my insurance says I'm allowed to have. 
Kathi52  
#13 Posted : Tuesday, January 05, 2010 1:56:13 AM(UTC)
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"Mallen, Keep in mind that that is true only if it is a Medicare covered item. There are a lot of things that are not covered by Medicare. In that case, Blue Cross reimburses, in my experience, very well."
 
I agree.  As I said in another post, I have had BC/BS for 30+ years and am a spinal disorders patient.  NEVER have I been denied a thing and I see my Specialists ALL the time.  I have to admit though, there were two times I was worried that they might not cover a "Bone Growth Stimulator" (I know it sounds funny lol) after two cervical fusions.  But BC/BS came through each time!  I am about ready to have another MRI and another procedure; with Medicare and BC/BS it works out beautifully...at least thus far.  And I would think since this was just ordered yesterday by my spinal pain management doctor and if there had been a problem, he would have told me.  But I guess I am good to go. 
OUtside  
#14 Posted : Tuesday, January 05, 2010 4:26:03 AM(UTC)
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Correction: in the last paragraph of my last post, I meant to say ‘…more than 115% of the Medicare rate..’ (not 15% of the Medicare rate). If it were only 15% of the Medicare rate doctors were permitted to charge, there would really be cause for worry!

As for items not covered by Medicare but covered by fehb, I am sure there are some here and there, but the point under discussion is whether federal retirees are subject to the Medicare rate for doctor visits not to exceed 115% of this rate. And the answer is generally yes, as far as I know, and it does not matter whether the retiree has enrolled in Medicare or has not enrolled in Medicare or whether the doctor takes Medicare or fehb (one or the other or both) or no insurance whatsoever.

Does anyone know differently and can refer to some definitive source?

mallen  
#15 Posted : Wednesday, January 06, 2010 1:16:36 PM(UTC)
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I know a lot of people I work with went with BCBS because they said that the other insurances they had simply would not pay things they should have.

 One thing that occurred to me is that Im not too concerned if some doctors wont take medicare. After thats the same issue that anyone with any kind of insurance has. The real question is,is anyone looking to see that enough doctors take it. Certainly part of the problem is the one size fits all payments without taking into account regional differences. Another problem is certainly the political nature of the levels medicare payments are set at. I have to agree that it is a very unreasonable system. A more reasonable way to do it,would be to index it to the average cost of medical care in a location,and to set the payments using a model of what percentage of doctors you decide you need to take it. In other words,if for instance,you decide that 50% of doctors in a region should be taking medicare to provide proper coverage for the recipients in that region,then you would set the prices so that you could expect that. If you found that many more doctors took medicare than you expected,you would dial back the payments next year,if significantly less,then you would increase them. The idea is to ensure there are enough doctors that take it,while keeping the cost as low as you can. To some extent thats what the insurance company does,except for an insurance company tries to maximize profits,within the constraints of the minimum levels of patient care,while any government run programs first priority should try to maximize patient care within the minimal level of acceptable finances,or at least that's my opinion.

Kathi52  
#16 Posted : Friday, January 08, 2010 6:40:59 AM(UTC)
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Good posts Outside!  For a more definitive source I would try the fepblue.org website and read "Medicare and You".  It speaks to the "limiting charge".  But keep in mind, this particular brochure is for those with Standard and Basic BC/BS.  I AM a bit confused as to what you said about retirees 65 and older. I am not there yet of course but my mother is.  She is a federal retiree and is 84; hasn't had a doctor yet refuse to accept her.  Then again, maybe it is because our Region.  Also, I have NO co-pays under Medicare Parts A&B with Standard BC/BS.  It is one of many incentives listed in the BC/BS Plan for electing Part B. 
Okiedoc  
#17 Posted : Thursday, February 25, 2010 7:28:34 AM(UTC)
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I think that there is some misinformation being propagated here.

Physicians do NOT have to limit their charges to 115% of the medicare rates.  Many insurances pay well in excess of that.

You have to understand that doctors do NOT have to contract/participate with Medicare.  There are basically 3 ways that doctors interact with medicare:

Participating:  The doctor contracts with Medicare, accepts "assignment" (the Medicare fee schedule), agrees not to "balance bill" the patient for the rest of what would be their usual charge, and bills Medicare directly on behalf of the patient. Medicare sends the payment DIRECTLY to the physician.

Non-Participating:  The doctor is contracted with Medicare, but does NOT accept "assignment."  However, the fees are limited to 115% of Medicare rates, AND the physician CANNOT receive payments directly from Medicare, but Medicare sends the payment to the patient directly.  The patient is expected to pay the bill, but not over 115% of the allowed fee.  The patient, as far as I know, CANNOT submit their claim directly to Medicare.

OPT-OUT:  the doctor is not contracted with Medicare, specifically notifies Medicare every 2 years that they are "OPT OUT status."  Physician can charge whatever he wants to a Medicare patient, and MEDICARE WILL NOT REIMBURSE ONE CENT OF THOSE COSTS TO THE PATIENT OR THE PHYSICIAN.

So here is what would happen in my practice if I said that I'm not accepting new Medicare patients, and you said you didn't have Medicare (and you do), but then I found out later that you do:  I'd fire you.  Because you're putting me at risk of federal law violation for breaking contract with Medicare.

freeageless  
#18 Posted : Thursday, February 25, 2010 8:52:25 AM(UTC)
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Okiedoc, that is basically correct. However, the 115% only applies to Medicare COVERED procedures. If it is NOT a Medicare covered procedure, the non-participating doctor can charge whatever he wants to. This is important because Blue Cross standard covers a number of procedures that Medicare does not.

Quote from Okiedoc

"Non-Participating: The doctor is contracted with Medicare, but does NOT accept "assignment." However, the fees are limited to 115% of Medicare rates, AND the physician CANNOT receive payments directly from Medicare, but Medicare sends the payment to the patient directly. The patient is expected to pay the bill, but not over 115% of the allowed fee. The patient, as far as I know, CANNOT submit their claim directly to Medicare."

Okiedoc  
#19 Posted : Thursday, February 25, 2010 9:04:37 PM(UTC)
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freeageless

Yes, but your original post didn't have anything to do with services not covered by Medicare. 

It was about how to get a physician to see you when they are not taking you as a Medicare patient.  Simply saying that you don't have Medicare isn't the right thing to do, as it puts the physician at legal risk with the government.  (i.e. it is not legal for the physician to accept direct payment from the patient if he is a participating physician, and it's also not legal for him to charge you his entire fee if he is non-participating, and it's not legal for him to bill you at all if he is Opt-out, knows that you have medicare, and doesn't have you sign a private contract with him first).

Whether Blue Cross standard covers other services or not as a secondary insurance has nothing to do with the issue of getting into see a physician who doesn't accept you as a Medicare patient.

quote from freeageless

"

If you want to go to a doctor who does not accept Medicare patients,
can you just tell the bookeeper if he or she asks that you do not have
Medicare even if you do have it. Then can you just go ahead after you
see the doctor, pay them yourself, and then submit the bill along with the Medicare form, and possibly see some reimbursement from Medicare"

Okiedoc  
#20 Posted : Thursday, February 25, 2010 9:08:38 PM(UTC)
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suezeekay

No, there is no law to that effect.  Participation in Medicare or not, and whatever a doctor charges outside of Medicare is completely up to the doctor. 


"Isn't there some law that if you are over 65, on Medicare or not, that
the doctor can only charge you 110%of what Medicare reimburses?  I have
BC and I didn't sign up for part B so I'm only constrained by the Part A
hospital coverage as far as I know."
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