Saturday, May 04, 2013

The Joys of Medicare

This isn’t a rant, although it’s tempting.  No, this is just a few curiosities about the inner workings of the Medicare system as I attempt to interact with them.

I opted into Medicare part B later than most, after retiring in my 67th year.  But I had been covered by my employer’s plan until then so all was fine.  About 10 months later I was scheduled for a routine physical exam, including a couple of tests.  Medicare promptly declined payment for the exam and the tests.

I phoned the Medicare 800 number, fought through prompts and a lengthy hold before being connected to a very articulate and well-informed representative.  After review he informed me that the problem was all in the coding of the claim.  The doctor had submitted the claim as a “routine physical exam,” but under Medicare I was not eligible for that code until I had been in part B for 12 months.  Then the representative brightly informed me that if the claim were resubmitted as a “welcome to Medicare” visit, it would be covered.

Okay.  How about the tests?

The answer, also delivered brightly, was that those would also be covered if resubmitted under a different code.  I asked which code he would suggest.  He said he was precluded from making suggestions for fraud prevention reasons, but assured me that “any code would do, other than the one that was used.”

Okay.  Gee, that sounded like very effective fraud prevention, wouldn’t you agree?  (Sarcasm font needed.)

Then last Tuesday I went to a dermatologist for a routine screening.  He found a small mole on my back that he wanted to biopsy, telling me it was probably benign but he thought he detected a color change and “better safe than sorry.”  I readily agreed.  (Duh!  That’s why I go see the guy!)

The phone call came yesterday that I had a BCC (“basal cell carcinoma”).  These are fairly innocent little skin cancers that rarely spread (metastasize), and are almost always successfully treated by removal of all the affected tissue.  Especially after early detection.  (Note to reader:  Routine dermatological screenings are a GOOD IDEA!)  The doctor wanted to schedule me for a return appointment to remove surrounding tissue to ensure complete removal of all affected cells.  This is typically done in the office (outpatient) under local anesthesia by freezing or burning around the biopsied area.

I was offered May 14 for an appointment, and of course agreed.  In the interest of getting rid of the cancerous cells as quickly as possible, I mentioned that I would be available all of the week prior to the 14th if there were an opening.  I was told, “Oh, we can’t schedule you any earlier because Medicare requires a waiting period.”

Excuse me?  More fraud prevention?

As I wrote at the beginning, this is not a rant.  But if the diagnosis had been a melanoma or something more serious, it would be!

Maybe there’s a (good?) reason.  But I’m curious, and plan to do a little more research to see if I can find it, and the “logic” behind it.  I’ll let you know.


Steve said...

I'll have to sign up in two years when I hit 65. Being overseas (Germany it works a little different and I will need to educate myself.

Duke_of_Earle said...

Steve, I spent the last 30 years as an HR and benefits manager in industry. I understand health insurance, ICD9 codes, and all that. But Medicare seems awfully convoluted. I'm all in favor of fraud prevention, but I don't see it happening based on my experiences thus far.

Steve said...

I guess I have something to look forward to or not.