Amy,

Thank you very much for your response. It looked like I have no way to know what the reinbursement should be.

My first phone call to the insurance company was pretty lengthy, the representative is very nice, she went through all the records, then told me that the code they have used for the initial 10 treatments was 99183 (hyperbaric oxygen treatment) but they have used another code (hospital service ?) for the final 10 treatments, so it caused problem. She agreed with me 100% that for the same hyperbaric oxygen treatment, 99183 should be used for all of the service.

However, the insurance did not adjust the statement. When I called again, the story changed, they said that correct code has been used for all the treatments, but
they have mistakenly used the "old" provider contract for the initial 10 treatments.

So far, I have made about half dozen phone cals times regarding the issue, talking to several representatives, spent long time explaining to each one of them of what had happened but always got a different answer, that is why I started question what should be the correct answer.

I guess if I was overcharged consistently from the very begnning, I would have paid the bill without any doubt. Right now, I know there are discrepancies, and the story kept changing, it is quite frustrating for me being unable to find out the truth but to believe whatever I was told.


Thanks for your help

WZ,
Your insurance person is correct about using 99183 to identify/charge the hyperbaric oxygen therapy session. 99183 is specifically defined as physician attendance and supervision of hperbaric oxygen therapy, per session. Be careful though because other codes can be added to this that can change the reimbursement for your visit. For example, if you had an examination or other procedure in the hyperbaric oxygen treatment facility in conjunction with a therapy session other codes would be reported for those procedures, etc. If you really want to get to the bottom of this I would call your physician's office and ask them for copies of the claims submitted to your insurance company and pair them up with the explanation of benefits (EOB) you got back from your insurance company (by date of service). Compare the codes by visit and between the claima nd the EOB and note descrepancies. I would be happy to review those with you and help you determine who to talk to at the insurance company and what to tell them you need/want.
Amy

Hello all,

I wanted to post a few tips that we have learned through Heather's ordeal. And I thought it would be a good idea to bring this topic back to the front page of the forum. These tips aren't exactly about bills, but they are about insurance.

#1. Find out if you can have a Case Manager at the insurance company assigned to you. It is much easier when you can talk to the same person all the time. I feel you get much better service.

#2. Don't assume that because something was paid for while you were in the hospital, it will be paid for when you are at home. The meds to bring Heather's blood counts up were paid for 100% when she was in the hospital. Once we got home, the ins. co. wanted them to go through her prescription plan. Her plan only pays 50% and we are talking about shots that cost $2700 each!!!

#3. Don't assume everything is written in stone. Because we talked to the right people and because we had a personal Case Manager, we got the ins. co. to pay 100% for the shots. The doctor needed to write a Letter of Medical Necessity, which was reviewed by the medical director at the ins. co.

#4. Don't be shy. We pointed out that we were saving the ins. co. thousands of dollars by caring for Heather at home. And that it would be easy to re-admit her to the hospital, because her health is still in a very precarious state. They could pay for a few shots or pay for her to go back to the hospital. I think they decided that a few $2700 shots was a lot cheaper than another hospital stay.

More later. Happy 4th, everyone!

Rainbows & hugs,
Rosie

Hi Rosie,
Great advice. All lessons hard learned I am sure. It makes me even more grateful for Kaiser Permanente HMO which covers almost 100% of everything. $5.00 deductible for doctors and prescriptions ($15.00 if no generic). In hospital, chemo, radiation, free. Any test I need, they just order it, no debates, just efficiency -I was always moved to the front of the line for all the scans. Years ago I had Kaiser and I hated it -they have really cleaned up their act. Since I also see a doctor at UCSF (radiation oncologist) they pay 100% of that also. It certainly is an advantage to have coordinated health care, rather than going to a bunch of individual providers scattered around town. In the cancer arena, comprehensive cancer care centers make a lot of sense (and I am refering to ones on the NCCN list, not that new age "...of America" thing). http://www.nccn.org/

Rosie,
All great advice!! And the key word is persistence...one that I'm sure many of you know well. All too often insurance companies take advantage of patient's lack of knowledge about their rights and the healthcare world we live in. Speak up! If something doesn't feel right it probably isn't.
Amy

Hi Amy and everyone else,
I hope I'm posting this properly. My mom's oral surgeon offered to send a claim to Medicare. Because the biopsy came back positive for SCC, the excision was deemed medically necessary. However, unknown to my mom, the oral surgeon is not a Medicare participating provider. Therefore, Medicare doesn't want to pay the claim. I intend to appeal the claim because there's no argument of necessity, the problem is bureauacracy. Do you have any thoughts on how to structure this claim? Do I complain to the oral surgeon? Any thoughts would be appreciated.
Thanks.
D

Didier,
I responded in detail to your email to me on this same topic. I did want to post something here however becasue I think you've raised some good points that others could benefit from. Some of the best cancer centers in the country have great diffculty getting reimbursed for oral procedures. Causes of this range from dentist performing the procedures rather than an MD to physician participation (with medicare) issues to beneficiary coverage issues. There are different types of Medicare and coverage does vary. Also just because a physician is nonparticipating does not mean the beneficiary can't be reimbursed for services or that an assignemnt of benefits can't take place. Didier, if you'll respond to my questions that I emailed you, I will be glad to help you structure your appeal letter.
Amy

A note about DDS's (doctors of dental surgery)...

I spoke to CMS about DDS's today. DDS's are a recognized provider but they have to enroll in the program much the same as MD's do. DDS's are not eligible for the opt out option under Medicare (but DDS/MDs are) so they can either enroll or not enroll (they can't contract privately with a beneficiary)...and if they enroll they then have the option to participate or not participate. There is no law, rule , or reg that says non-erolled DDS's have to inform beneficiaries that they are not enrolled in Medicare (but they should if they want to do the right thing). If your DDS is not enrolled in Medicare, CMS says you can still be reimbursed for the biopsy (excision of the oral cavity, etc) because it is a covered service BUT the beneficiary will have to submit the bill for reimbursement themselves. CMS cannot reimburse the DDS directly if he is not enrolled.