Medicare coverage...

I thought I'd pass a couple of items of note regarding Medicare along to those of you with this type of coverage.

Currently Medicare's coverage of PET scans is limited. In April, the Centers for Medicare and Medicaid Services (commonly known as CMS or HCFA)announced they will expanding coverage to include treatment of patients with thyroid cancer.

Another hot topic of late for Medicare recipients is that of medical necessity and Advanced Beneficiary Notices (ABN). Please understand that it is the physician's responsbility to identify and ensure you are informed of any procedures or treatments that s/he intends to order/administer that are not covered/reimbursed by Medicare. Of course s/he gets assistance from other clinicians, staff, and computer programs but ultimately it is the physician who orders and must understand what tests/procedures are allowed with which diagnosis. What does this mean to you? If a test/procedure is ordered that is not supported by your diagnosis you will likely be asked to sign an ABN. This means that you will be responsible for payment. Talk with your doctor about this prior to signing. You must be given ample opportunity to understand, question, and decide whether or not to have the test/procedure (and sign the ABN). Healthcare providers cannot make you pay for something that Medicare denies for payment if they do not have an ABN on file, signed by you for that specific service. Healthcare providers also cannot present you with an ABN if it is not warranted (blanket ABNs are not allowed).

Also, please be aware that healthcare providers can appeal denials (refusal to pay) from Medicare if the physician feels the test/procedure you received is clinically warranted whether or not you signed an ABN. So if you receive a bill for something that you feel should have been covered by Medicare, talk to your physician or hospital billing office about it. I have heard of cases where cancer patients were asked to sign ABNs for chemotherapy treatments for recurring cancer treatments. If your physician determines chemo is warranted and beneficial to you, any denial can be appealed.

P.S. This ABN stuff applies to all healthcare services provided to or offered to Medicare patients. Also, be aware that ABNs cannot be offered unless the patient is stabilzed and able to understand (in other words asking a trauma victim with Medicare coverage to sign an ABN when they arrive at the ER would be higly inappropriate).

Let me know if I can help or if there are any other topics of interest.


Amy