Hi-when I was first diagnosed, 4 years ago, I was still working and my insurance covered everything but the co-pay. Now, I have retired, not on disability and have Medicare and a very good supplement insurance. I am now in a new area and found a doctor who only does Sjogrens. It is a University hospital group. I use this center for oncology and all my other doctors. They always take my insurance cards and I have had no problems. When I got this appt.--for October- they said bring your insurance card too because Medicare doesn't really pay. Has anyone else had this problem? When I searched for all rheumys in the area for Medicare, nothing came up. But, many people over 65 have arthritis conditions.They must have medicare.
Any thoughts on this?
Thank you
Lesley
Lesley,
I have medicare and a very good supplement. This is the first I have heard that Medicare "doesn't really pay". When I get my Medicare statements, it is clear that they DO pay. It is also clear from the statements that what the original charge from the doctor or tests submitted is, that a portion is written off by Medicare pursuant to what the doctors agreed to accept. That difference is not billable to the patient.
My annual deduct for Medicare is low and once met, 80% of the contracted amount (per doctor's contract with Medicare is my understanding) is covered by Medicare (I should mention I have traditional medicare in case it matters) and once deduct is met on supplement, supplement picks up 80% of what is left as balance due fro the Medicare end.
Now, what I AM encountering this year from two of my doctors thus far, is that some tests are limited to once a year. My endo stated the Vit D test is covered only once a year. Well I need it 4xyear. His lab informed me similar restrictions have been placed on other labs, for example affecting their diabetic patients.
So I called Medicare directly and inquired about that. Short answer (and I was on the phone with the woman there over an hour while looked under every nook and cranny) - on some tests the doctors must call the physician line to precertify medical necessity. Once they do that, the respective test is COVERED.
Now I am really trying hard not to ascribe attributes to certain doctors that may or may not be merited. I recently came across with my PCP that he was WILLING to order MRI soft tissue neck W&WO but "they" might not do it out of concern they might not be paid. I haven't talked to Medicare on that yet, as I am waiting to see what ENT decides today. Oh, and PCP did NOT order the test.
But my lesson in all of this is if you're being told Medicare won't pay this or that, VERIFY directly with Medicare. When I called, I gave a brief synopsis of my situation and my concerns and of course Medicare can't give me a specific answer in advance of a test or claim, but she was very helpful in clarifying WHAT THE DOCTOR needs to do to get a certain service or test covered.
I am aware that Medicaid presents a whole new set of challenges in finding doctors who participate in it. Numerous doctors across the country have been reported to have dropped Medicaid patients entirely. I've had the concern running in my mind that it is only a matter of time that we Medicare patients will eventually encounter similar barriers.
Amanda
