Senior Client Had Plastic Surgery

[vic120]

I would think when she set up appointment they asked about Insurance, and had to at one point tell her what the charge is especially when the charge is that high, You would think she would have investigated this beforehand.

I get calls from clients beforehand and have helped some avoid unnecessary charges, Because it was before hand

 

[sman]

I received an email from a client who has a Plan-F MedSupp with me.
She said her Dr had advised her to have her eyelids reduced as this was blocking her visibility. She received a referral to a Palm Springs plastic surgeon
who subsequently performed the procedure.

The client wants to know how she can file the claim. I was never informed
of her intention to get the surgery. I gave her the Tel # of the MedSupp company and instructed her to ask for customer service. I asked that she call me later if she had any questions once she talked to customer service. She wants to be reimbursed $2500 for the surgery plus $95 for the optometrist.

My concern is that she may not be covered. How should I have handled this?
Thanks.

I'm just curios as to why you instructed her to contact the Med Supp carrier? The Med Supp isn't going to do anything unless and until Medicare processes and approves the claim. Med Supp selling 101 is understanding who the primary insurance is with. And when someone has a Med Supp, that means Medicare is the primary. The Med Supp does just what its name says, it supplements Medicare.

 

[somarco]

Lost in this discussion is any mention of an ABN form. Any chance she signed one?

 

[LostDollar]

Lost in this discussion is any mention of an ABN form. Any chance she signed one?

My education is not an issue of concern in this thread, but I just wanted to say thanks for posting this. It is material I had not heard of and need to know about. It will take me awhile, but I will get through it eventually. As i started reading, I see questions I am going to have, but given the "fan club" following I have developed here, asking them here is likely not a productive approach. At any rate, thanks for sharing the info.

 

[sman]

My education is not an issue of concern in this thread, but I just wanted to say thanks for posting this. It is material I had not heard of and need to know about. It will take me awhile, but I will get through it eventually. As i started reading, I see questions I am going to have, but given the "fan club" following I have developed here, asking them here is likely not a productive approach. At any rate, thanks for sharing the info.

Asking questions isn't the problem. It's when you state something as fact when it's not is the problem. Or give incorrect advice. Or worse, you tell an experienced person they are wrong when they aren't. Those are the reasons you have a "fan club".

 

[WCMason]

My mother, 72, had this surgery a couple of years ago while enrolled in a UHC HMO Medicare Advantage plan. The plastic surgeon had to get it pre-authorized as medically necessary due to vision loss and it was approved. Her only cost was the outpatient surgery co-pay. Original Medicare should cover it, too, if the beneficiary goes through the steps of proving medical necessity. That may be the hitch in this case.

 

[yogooglethis]

My mother, 72, had this surgery a couple of years ago while enrolled in a UHC HMO Medicare Advantage plan. The plastic surgeon had to get it pre-authorized as medically necessary due to vision loss and it was approved. Her only cost was the outpatient surgery co-pay. Original Medicare should cover it, too, if the beneficiary goes through the steps of proving medical necessity. That may be the hitch in this case.

What WCmason said.Also The Medicare Advance Beneficiary Notice of Non-Coverage (ABN) can come in to play here because this procedure is sometimes covered by medicare.


I had a very similar situation where the plastic surgeon led the client to believe it was covered on her UHC PPO MA plan so she filed a grievance to medicare and the provider had to eat the bill .


Mandatory Use of the ABN

An ABN must be used to convey to the beneficiary that a provider believes that an item or service will not be covered when:

The item or service is not reasonable and necessary; or
The item or service is provided in violation of the prohibition on unsolicited telephone contacts; or
The item or service is for medical equipment and supplies for which the supplier number is not provided; or
The item or service is for medical equipment and /or supplies denied in advance;
The item or service is for custodial care; or
The item or service is for hospice care provided to a patient who is not terminally ill.[10]
The ABN is not required for items and services that are never covered under the Medicare statute (statutorily excluded) or for items and services that do not meet a technical benefit requirement (such as a required certification by a provider, physician/practitioner).[11]

 

[somarco]

Sometimes blepharoplasty also can improve your vision by providing a less obstructed field of view, once droopy eyelids are improved.

A functional blepharoplasty (in contrast to a cosmetic blepharoplasty) is eyelid surgery performed for medical reasons.

 

[TwoCents]

My education is not an issue of concern in this thread, but I just wanted to say thanks for posting this. It is material I had not heard of and need to know about. It will take me awhile, but I will get through it eventually. As i started reading, I see questions I am going to have, but given the "fan club" following I have developed here, asking them here is likely not a productive approach. At any rate, thanks for sharing the info.

Wait, what? So Somarco starts off a sentence with the word "Lost" and LostDollar thinks he's referring to him? Wow.

 

[LostDollar]

Asking questions isn't the problem. It's when you state something as fact when it's not is the problem. Or give incorrect advice. Or worse, you tell an experienced person they are wrong when they aren't. Those are the reasons you have a "fan club".

Thank you for making a respons for me that is not filled with hyberbole and invective. Nice to get one of those. the fact that FLM2 feels free to stick criticism of my buying choices in random spots and that somarco will "like" a post that is critical of an effort on my part to thank somarco for sharing information which is of use to me, in addition to meeting the purpose of a thread, suggest to me that i am at the point where just asking the question is a problem.

May i start another thread and ask you a medicare related question?

(sorry about typing-left handed only for awhile.)

i have something i've bee trying to work out. It would present wonderful opportunities for LD bashing and i have no interest in trying to ask unless i have a chance of geetin a real answer amongst the pokes.