Can't get a definitive answers about Medicare's secondary coverage policy (xpost)

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

Barbara, I think you may find this link helpful: http://www4.law.cornell.edu/uscode/html/uscode42/usc_sec_42_00001395---y000-.html I'm looking closely for a specific clause that would apply to your husband...

Hi Larissa -

First let me thank you for taking the time to research this and to respond. My mind is a bit foggy this afternoon, so I have to wade through the text again later when I can hopefully sort through it a little better, but I don't think I find anything that excludes payment ... I don't think I find anything that says that they will pay when they are the secondary payer, if the primary doesn't cover the expense. I need to look at it again when I might be a little clearer.

Thanks again for the response to my post. I truly appreciate it.

Barbara