Cant get a straight answer out of Medicare regarding coverage as a secondary provider

I had my RNY last summer. My husband had been contemplating WLS before me, but didn't take the leap. Now, he's decided he'd like to. I'm hoping that he will be able to.

While he meets all the criteria ... and then some, we are having some insurance issues that may not be surmountable. I'm praying things will work out.

Medicare is the secondary provider because he has major medical through his employer who has more than 100 employees, so his employer's insurance is primary. Unfortunately, his employer has a "specific exclusion" against ANY treatment for morbid obesity ... I could go on about what I think of that, but it doesn't really matter right now. Medicare becomes the secondary insurer when you have a major medical plan covering more than 100 employees. Whenever I have called Medicare, they have said yes, we'll pay because it's a covered benefit if he meets the criteria (...he does, in spades!) 

When I spoke with the surgeon's office (Duke) they said ... "I don't care what the representatives at Medicare told you, they will deny the claim when it is presented because Medicare will follow suit after the primary. It doesn't matter why the primary denies the claim, if the primary denies the claim, it will be denied automatically by Medicare."

I've been trying to get a "Straight" answer from Medicare on this issue. It's been escalated to their admistrative office in Determinations. Apparently, it's considered a "gray" area. I want an answer, in writing. I honestly don't know who to talk to anymore and what to do, because Medicare requires that the procedure be done at a Medicare recognized Center of Excellence. Duke is it in our area. Duke won't see him unless I get something in writing stating that the claim will be paid if he meets Medicare Guidelines regardless of the decision of the primary carrier. I understand that they need and want to get paid. I need and want Medicare to do what they keep telling me that they do; which is cover any Medicare eligible expenses if the primary doesn't cover it.

If anyone has a suggestion, I'm all ears.

Barb

tell him to quit his job for a month....   maybe?  then Medicare will become primary?  It sounds like a bunch of rigamarole to me....  is there another center of excellence around?

There are 8 Medicare recognized Centers of Excellence in North Carolina. It is my understanding that none will touch him with a 10 ft pole unless we can get a "positive" clarification on this issue. It is an option I'll explore if necessary. At this point, I'd like a straight answer out of Medicare. As you know, sometimes when working with beauracracies can be a difficult thing to do. Often, they are not as documented in their policies and procedures as we wish that they were. I know that they do sometimes pay as the secondary provider, but it is rare. I need to find out what they use for determination criteria.

I don't think that having my husband quit his job is likely to be an option for a myriad of reasons. We'll have to see what we can do.

Thanks for the input and support.

Barb

Barbara I can hear your frustrations and I am sorry this is going on with you and your husband.  How ridiculous that you cannot get a straight answer and I wonder if you ever will.  I hope your husband doesn't give up...Don't let him.  He took this leap and I really hope that Medicare doesn't make him have second thoughts.  I guess keep him as pumped up as you can that this will be resolved.   I don't know anything about Medicare coverages, but I do know that they pretty much can make life miserable.  I saw it first hand with my mother during a severe illness before she passed.  It is a true jumping through hoops sometimes just to get heard.  I am truly sorry that you are dealing with this.   Hugs Connie

Thanks Connie -

I'm working on it. I too have Medicare coverage, but Ben wasn't working when I had my surgery, so it wasn't an issue. I'm working with Medicare and Duke to see what we need to get this done. I'm mad, but not done and not giving up. Ben is too important.

Thanks again,

Barb