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Any People Know (or Know Someone) Who Is Medicare Savvy???


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Situation:

I have 2 insurances, one with my husband, the secondary is Medicare (for the disability).

I called up a "lyme literate" doctor in my state to set up an appointment.

She asked for my insurance(s)? I told her.

She said,"We don't accept Medicare." I said "Medicare is my secondary. I have other insurance as my primary."

She reiterated, "We don't accept Medicare." In continuing to ask her questions, I found that this doctor is one of those "out of the network" doctors that expects me to pay in full up front and (after they would file for me), I would get reimbursed.

I continued being a bit of nuisance and said,"I will be paying you my own money out of my own pocket. Why can't I be a patient of yours if I'm paying? I won't file Medicare. You won't file Medicare. What's the problem?"

"We don't take Medicare patients."

Then, I went to a lymenet forum and asked about this, and was told by one responder, "You won't find any Lyme literate doctors in your state that take Medicare patients."

I am totally baffled?????? I will eventually understand what is going on here, because right now, I'm missing pieces of this story, and it does not make sense.

I'm willing to pay out of pocket for medical services. Medicare is my secondary insurance, and this physician won't take me as a patient because I'm a "Medicare patient".

Please, anyone with some insight on this......EDUCATE ME.....I know there is some logic in this story somewhere?!

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I am a little unclear so let me first try to clarify

1-You have primary insurance through your husbands employer? Yes?

2-Do you know if the Dr you want to see accepts your husbands insurance and/or do you know if that insurance company would consider this Dr and "in-network" benefit or "out-of-network"?

Based on what I think I understand you saying, these are the steps I would take....

1-I would call the primary insurance carrier and see if this Dr would be considered in-network or out of network.

I would also ask them if I was allowed to file the claim myself if the Dr's office makes me pay all fees up front (that should be allowed but you may have to get special forms from them). Also, tell them that this Dr does not file Medicare; ask the primary insurance carrier if THEY can file the Medicare claim for you after they have processed the claim on their end.

2-If Primary Insurance says they can't file the secondary Medicare claim for you then Call Medicare --remind them they are secondary payer. Ask them if you see a Dr. whose office says they do not file Medicare if you are allowed to submit the claim yourself AFTER your primary insurer has paid and ask them if you need special forms from them to submit the claim yourself.

Make sure you get an address from Medicare where to send your claim to and/or ask if there is a fax number you could use to submit the info.

3-If you get the answer from the above sources that you can file the claim yourself call the Dr's office back. When they ask what insurance you have ONLY give them your primary insurance information. I wouldn't even mention that I had Medicare as secondary.

4-If you go this route---make sure you get ITEMIZED bills for ALL services and fees the Dr' provides (this means that sometimes you have to call the billing office and ask for an itemized bill if all they send is a statement). If you submit the claims to medicare yourself make sure you make copies of all EOB's from the primary insurance carrier to submit along with the bills. Make sure you keep complete copies of all information you send to Medicare.

***To answer your question about the "logic" to this. It could be several things

#1 Many Dr's offices are not used to Medicare being a secondary payer and don't understand the rules about it.

#2 If the Dr does not file insurance then they probably don't have the ability to file electronic claims with Medicare. Medicare has made some changes over the last few years and I believe one that is fully implemented now is that in order for the Dr to receive payment from Medicare the Dr has to be "signed up" and have access to their electronic system.

When they are telling you they don't take Medicare patients I think they are basically telling you they don't have an agreement to file with Medicare. It would be a big issue for you if Medicare was primary but in your case I think I would only tell them about the other carrier.

The majority of people have Medicare as primary and another carrier as secondary or supplemental policy and most Dr's offices get confused on how to handle medicare as secondary payer.

Hope this helps in some way

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I agree with Poohbear. I think seniors (I'm not one, but have family members who are B)) have Medicare as first insurance and supplemental as secondary. So the doc may just be confused. Can you talk the person in her office who handles the claims? Maybe they would understand the insurance rules better.

There may be reasons why this doc doesn't want to deal with Medicare (or even the possibility of Medicare). Even if you submit claims on your own, the doc has to fill out some forms for you, which she may not want to do. Or she may have had problems with them in the past.

I know very little about lyme, but have heard that some of the lyme docs don't take any kind of insurance. If you think just medicare is a problem, consider mentioning just your main insurance to get an appointment. Then call back before your appointment and clarify the Medicare part to make sure you are covered.

I wonder if this doctor is eager to take on new patients. My docs (even if they are terrible with the medical stuff) always go out of their way to help with insurance - I always let them call the ins co for me so I don't have to deal with it. In getting treatment for something so specialized, it might be important to get someone who wants you as a patient, listens to you and wants to work with you on financial/insurance stuff.

Good luck and let us know how it goes.

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medicare is my primary do to being disbled.Often my doc will send me to docs who won't take my secondary. she tells me to just use my primary and not even use the other. many write the rest off and when they don't she asks them if they will for me.

i hope you can work it all out.

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