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When a person goes in for an outpatient surgical procedure

Customer Question
and the healthcare provider accepts...
When a person goes in for an outpatient surgical procedure and the healthcare provider accepts your medicare coverage on assignment as well as your Supplemental Insurance policy, is it up to the healthcare provider to accept what is paid by the policies? Is it up to the healthcare provider to inform the patient if something is not covered or if something is not covered? Too bad as assignment was accepted and the patient is not liable for something Medicare will not pay for so the supplemental policy does not have to pay anything either and the patient is off the hook?
JA: What state are you in? It matters because laws vary by location.
Customer: Tennessee
JA: Has anything been filed or reported?
Customer: I have been dealing with this for months with documentation. $240.00 were for photos of my right eye and at the bottom the claim it states that the provider was not qualified to receive medicare payments. The other was $1845.00 for surgery to remove the eye lid caused by Graves Disease to correct an eye muscle. It says Medicare did not approve the charge. I believe it was coded wrong or if was considered an elective procedure should I have been informed on the front end? The Doctor billed for the procedure with no reimbursement and the facility billed for the procedure and received reimbursement. Both describe the procedure as "Surgery to move the eyelid". The doctor billed for $1,845.00 with no reimbursement and the facility billed $3,150.00 with reimbursement of $368.55. $294.84 Medicare $73.71 from supplemental policy. I thought the doctor needs to re-code the procedure but it seems easier for them to try and collect from a senior citizen on social security with a part-time job.
JA: Anything else you want the lawyer to know before I connect you?
Customer: No? I am a semi-retired pharmacist and I think they are too lazy to re-submit the claim with the proper code to get reimbursement. I just keep getting the run around and today I get a letter from a collection agency for reimbursement and I am writing to them with disgust because lazy accounts receivable or payable departments would rather intimidate me with a collection agency than do their job.
Submitted: 2 months ago.Category: Legal
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Customer reply replied 2 months ago
Should I call Medicare myself to ask them why the Doctor did not receive payment of any kind while the facility where the outpatient surgery was done did receive payment. Both bills were described with identical wording "Surgery to move the eye lid". I realize that in healthcare reimbursement is often based on the "coding" of a procedure and my supplemental policy which sent me information on what medicare covered and what portion they paid for other charges on my bill summary just made the statement "Medicare did not approve the charge". I realize that physicians are busy and all they are concerned about is doing the procedure and have no time to worry about payment. What irks me is that I know claims can be re-filed and "coded" differently to maximize reimbursement. Someone is capable of doing this but who in this Physician Group will take the time is the frustrating question without an answer? I just think whoever is responsible for obtaining reimbursement for services performed by this physician group could care less and it is much easier for them to drop the ball or "kick The Can" down the road to me instead of doing their job. Who cares? Just send out a bill as it does not concern me so why should I care?(that is the responsible parties attitude in that physician group). I have even sent a copy of the bill asking them why the facility was paid and the doctor was not. Do you think they could respond in writing to my inquiry? That would mean they would have to respond to a legitimate question and someone would actually have to come up with a suitable answer. Instead of looking into the matter, it is much easier to ignore my inquiry and just send the bills to a collection agency. I understand what goes on in healthcare as I have worked and dealt with reimbursement in the past. I do not know who in that physician group is responsible but they have my information so they cannot plead ignorance. I am going to call Medicare and then I am going directly to the person responsible in that group who is ultimately responsible and demand that they be fired by whoever they report to. They are completely aware of my inquiry since February 2, 2017 and they have not been ignored by me and have all of the facts with no response from them. The thrust of my question to you is that when my medicare and supplemental policy was accepted on assignment in the State of Tennessee it was offered by me and accepted by them in good faith of both parties and all that they would be reimbursed for is what the policies covered and I was responsible for nothing more or nothing less. And if so in retrospect was it up to them to inform me or to spring charges on me on the front end say they could not accept "assignment" on my Medicare and United Health Supplemental Policy thru AARP. What is so frustrating is what I asking you I asked of them with no response. It is not as though I have ignored there bills hoping that by some magical "fairy dust" they would stop. I have made copies given them to two physicians mailed my inquiry to the physician group hoping it would find its way to a responsible party who would answer me. They cannot plead ignorance when I walk into their office and have a sit down discussion which I plan on doing today as I have had the run around long enough. The collection agency was the last straw in my normally easy going temperament.
Answered in 12 hours by:
9/6/2017
Lawyer: Phillips Esq., Attorney-at-Law replied 2 months ago
Phillips Esq.
Phillips Esq., Attorney-at-Law
Category: Legal
Satisfied Customers: 19,845
Experience: B.A.; M.B.A.; J.D.
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Lawyer: Phillips Esq., Attorney-at-Law replied 2 months ago

I am sorry to read about your difficulties.

First and foremost, you need to contact Medicare to find out why the facility received remibursement, but the doctor did not. You can then pass this information along to the doctor's account receivable department.

As for the doctor/facility being responsible for the payments because your insurance was accepted, regrettably, the patient is ultimately liable for the bill if the insurance does not cover the procedure. However, if you did go through the procedure on the promise that the procedure would be covered by your insurance, then you can refuse to pay the uncovered bill using the implied contract theory of detrimental reliance. That is, you would argue that but for the promise that was made to you, you would not have gone through the procedure and incurred the bill. So, you are not responsible for the bill. The facility/doctor is responsible for the bill.

As for the collections agency, you should send them a cease and desist letter to stop contacting you immediately with regard to the bill because you dispute the validity of the bill. Once you do this, the collector is prohibited by Fair Debt Collection Practices Act from contacting you with regard to the bill. However, they can file lawsuit to try to recover the debt. But if you are on Social Security and have only a part-time job, chances of them collecting are little to zero. Your Social Security payments are 100 % exempt from garnishment. Only 25% of your net wages can be garnished.

Best wishes,

A positive rating to my response is appreciated so that I can receive credit for responding to your post. There is no additional cost to you for giving a positive rating.

Thank you for your cooperation.

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Customer reply replied 2 months ago
Thank you for your response counselor. I appreciate your service and your sage advice. I will use your service again if necessary. Take care and may God bless you for your service is my prayer for you.
Lawyer: Phillips Esq., Attorney-at-Law replied 2 months ago

You are quite Welcome!

A positive rating to my response is appreciated.

Than you for your cooperation.

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Phillips Esq.
Phillips Esq.
Phillips Esq., Attorney-at-Law
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Satisfied Customers: 19,845
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