Medicare

HI--My husband has Mcare and BC and Mcare is primary.  THe Dr is having us sign a form that they say really doesn't mean anything cause Mcare will pay but it says on the form that "I understand that Mcare probably will not pay for open RNY and I agree to pay".  DH is kinda skeptical of that.  Is there anything to say if Mcare will pay and if so, how much will they pay?  ALso since BC is secondary, will he have to have the 6 months of supervised diets and all that that I have to have with BC as my primary?

Does Mcare usually pay most of it?

Confused but we want to make sure it is covered before we have it done.

Thanks,  Terry

HI Terry-
As your primary, Medicare will pay 80% of the allowable and BC should pick up th other 20% as long as it is a covered benefit under your BC plan. The allowable is the amount that medicare thinks is appropriate to pay for surgery and if you are doubly covered, then your surgeon's office cannot bill you for any balance. It is very common for practices to have you sign the form you spoke about...medicare does pay unless you do not meet the criteria. If you meet the criteria, Medicare will pay. Lastly if your BC plan mandates the 6 months of supervised diets, then you have to do them even when they are seondary....that is if you want them to pick up the 20%. If you choose not to do the supervised diet, then BC will deny the claim and you will owe the 20% of the medicare allowable. Make sense? Hope this helps.

Best,
Billie

 Hi Billie,

Maybe you can answer this for me, because I'm in the same boat.

I have regular ol' Medicare B, not a Medicare HMO.  Some info I have read states that Medicare pre-approves, but the doc I just got off the phone with said that Medicare (regular B, not hmo/advantage) does NOT pre-approve and therefore requires a $500 deposit from me.  Is this correct and in this situation, do patients usually get their deposit back?

And also of importance, this doc said that Medicare does NOT require the 6 month supervised diet while the two other doc's I've spoken with said that Medicare does.  They were explicit in telling me that the supervised diet was a condition of Medicare, not theirs, so I am utterly confused.  Can you shed any light on this?

Hello-
Yes, the doctor you spoke to is telling you the correct thing - Medicare B - regular Medicare does not pre-approve this surgery. It is a covered benfit under medicare if you meet the criteria, but they do not pre-approve. I have not heard of a practice collecting a deposit, but I can see the reasoning behind it. If for some reason Medicare does not pay (because they find that you did not meet the criteria - this would be the only reason) then the doctors office has covered some of their cost. So, I would imagine that you would get some of your deposit back when Medicare pays.

Also, regular medicare does not require the 6 mo WLP, only some of the medicare advantage plans do. I hope this helps! Let me know if you need more guidence.
Billie

 Thank you, Billie.  That is very helpful and explains a lot.  I just found out today that Colorado does indeed require 6 months supervised diet.  Each state or region has a different carrier which interprets Medicare's guidelines.  So Colorado's interpretation of "Previous Unsuccessful Medical Treatment for Obesity" is defined as 6 months of physician supervised diet effective 3/1/08.

I'm glad I finally have clarity on this and have seen the actual documentation, because it is the doctor's office that wanted my $500 that did not require the 6 months.  Which means I would have been out the $500 bucks if Medicare audited them and saw that I did not have the 6 months supervised diet.  

Many thanks!!!
Lisa