office visit not covered by Medicare?

I got my pacemaker December, 2021. All is great and I am feeling better. I went for my first 3 month checkup with my electrophysiologist and both Medicare and Anthem refused to cover the visit. What's up with that? I plan to call and ask why but wonder if this is common and maybe the claim was coded wrong?


14 Comments

Medicare

by Good Dog - 2022-04-04 13:49:44

If you went to the doc for the first time in 2022, you most likely needed to meet your medicare deductable ($233). Most secondary insurance does not cover that unless you have an old "F" or "G" medigap secondary plan. Medicare stopped allowing that deductable to be covered for most new plans in 2022.

Deductible!

by GeorgiaJammy - 2022-04-04 13:55:15

It is my deductible -- EOB was worded weird. 

Medicare

by Good Dog - 2022-04-04 14:26:10

Thank goodness for Medicare! Since too many people here in the U.S. do not want our government spending tax dollars to help people, I struggled during much of my working life with paying medical bills. Now that I have medicare and a secondary plan; I feel like I died and went to heaven! You gotta love Medicare!

Medicare deductible

by AgentX86 - 2022-04-04 14:58:24

Only Medigap Plans C and F have been discontinued for new applicants and only discontinued for people born after 1/1/1955. They're a bad idea now, anyway, because being a closed pool they will get more expensive over time. Plan-G does have the $233 deductible.  That's the only difference between Plan-F and Plan-G.

Plans C & F

by Good Dog - 2022-04-04 20:37:59

Yeah, you are correct. I incorrectly stated plan F and G. Should have said F and C. Don't get me wrong, because as I had said; I love medicare, but these secondary plans can be a real rip-off. Medicare Advantage is even worse! I calculated the amount that my secondary plan pays for the last several years and they are making a ton of money. I suppose that is true of all insurance companies, but then I do understand they are in business to make money. Health insurance is a real sore spot for me since getting a PM at age 38, I could not get health insurance except in a group plan at my job. Couldn't buy life insurance either after my PM. I could get some limited amount of life, but the cost was outrageous.

The rate on my Medicare secondary plan had gone up last year and so I decided to change plans and switch to a Humana Plan "G" that had a lower rate. I had to answer health questions when they took my application. I foolishly thought that they had to accept me, but turns out they did not. They refused to cover me. So I had to stay in my old plan and pay the higher rate. Hate is a strong word, but I hate insurance companies! Maybe a little more than cable tv companies.

Thanks for letting me vent!

Medicare suppliment

by AgentX86 - 2022-04-04 22:42:37

I'm the opposite.  I think the supplimental insurance is great (drugs are a whole different stinking kettle). I'm having surgery in the next couple of weeks and I'll pay zero (Plan-G) for any of it. I see a specialist about once a month will have a stress test in June.  I won't pay for any of it.  OTOH, my wife won't use her's enough to justify it.  Yet.  None of us will ever be as young as we were yesterday.

It was pretty clear that changing plans, except for some unusual circumstances, could only be done with medical underwriting.  There was only one get-out-of-jail free time where you could select the plan and company regardless of medical history. That's why I got a Plan-G suppliment and not from the cheapest company but one of the larger ones so the pool should be more stable.

You're right. Advantage plans are pretty bad, some more so than others.  Unfortunately most don't take the time to do their homework or assume they're going to be healthy forever.

Of course insurance companies are in business to make money.  Insurance is always a losing propositioin for the insured.  Rather like a casino. It's not easy to buy insurance after the house burns down or place chips on the roulette table after the ball stops.

charged

by new to pace.... - 2022-04-05 06:43:46

I have a different problem my heart center for the past nearly 2 years has yet to bill Medcare for the quartly  remote transmission's or the yearly in  office one.

 Was told since have nightly remote transmissions, the quartely one is so they can bill medicare.

Tried to tell them one time, but still no billing to medicare.

To change plans to a lower medicare supplement would be considered a new plan and would be charged an even higher rate.  I use AARP United healthcare, they now increase their rate in July. That way when you can change during the window in the fall.  You do not know what the new rate will be.  Then stuck with the higher rate for 6 months.

new to pace

Charged

by Good Dog - 2022-04-05 10:13:54

New to pace, I sympathize with you. I will always hate insurance companies, because I believe that they are just too greedy. Even though I had to get a PM at age 38, I have been really healthy otherwise for the last 35 years, and rarely go to the doctor (that is changing, so the noise you are hearing is me knocking on wood). Still, health insurance companies want nothing to do with me. They just want a sure thing! There I go again. Whining won't change anything. Sorry!

Anyway, AgentX86 is correct. Insurance is always a losing proposition for the insured. He is also correct about the drug cost issue. That can be a much bigger problem! I also have been fortunate in that I do not have to take any drugs, but that can certainly change at any time. There are some drugs out there that can really break you! I guess the cost can also kill you if you cannot afford them. Hopefully the government will eventually do something about it?

I hope you get your insurance issues straightened out and you come out on top!

Sincerely,

Dave

Charged

by AgentX86 - 2022-04-05 13:14:28

NTP, once you're in a MediGap ("Suppliment") policy, the only ways to change the plan or insurance company is if they pull out of your zip code, you move to a zip code they don't cover, get medical underwriting for the new policy, or drop out of Medigap completely. That's why it's so important to pick wisely, considering your future, when you first take Medicare.

The annual window is only for Medicare Part-C ("Advantage") and Part-D (drug) plans. Medicare Supplimental insurance is "for life".

 

Billing Insurance for Remote Monitoring

by Marybird - 2022-04-05 16:20:49

New to Pace, I just wanted to mention that the pacer tech in the cardiology practice I go to explained how remote monitoring worked in their office. She said that though the pacemaker transmits its data from your heart activity to your monitor every night, your monitor does not transmit that data each night to the manufacturer's website unless that data contains information that is outside the "normal"parameters set up for you got the pacemaker. For instance, if the data showed heart rates above the rate set for tachycardia alerts, increased mode switching ( in response to tachycardia episodes), lead problems, other indications there was a problem with you, or the pacemaker, the monitor might send an "alert" for the problem outside the normal scheduled remote monitor reports ( as in every 90 days). 

This tech explained to me that the pacemaker monitor reports go to a secure website maintained by the manufacturer, and the information on each patient is available to the clinic/designated person/doctor, either by their accessing the website, or in the case the data shows a problem, the doctor/personnel can be notified directly via text, email, phone ( they choose when they setup a patient initially.  In the practice I go to, the device clinic technician accesses all the reports, gets the alerts via text. She said she reviews the patients' medical records, if the report or alerts show a "new" or actionable" problem, she alerts the PA ( at least for the cardiologist I see), he goes through the records, kind of "triages" the information and passes it along to the cardiologist.

For billing of pacemaker monitoring reports, ( as well as for most other diagnostic or monitoring tests), there are two components. One is the "technical" component, for pacemaker reports this would be the bill for reviewing, compiling, and interpretation of the data submitted by the remote monitor to the manufacturer's website. This "technical component" may be done by personnel in a device clinic, by a third party cardiac monitoring company ( my cardiology practice uses Cardionet), or perhaps a clinician (EP) with expertise on interpreting pacemaker data. 

The second part of the bill for pacemaker monitoring would be for the "professional component", and this generally comes from the physician who receives the completed report ( completed by whoever reads and interprets the data), may make a diagnosis or a clinical decision for the patient based on the report. This physician signs off on the completed report. 

I have to admit to being confused about who bills when for my pacemaker reports. The first year I had the pacemaker, I never saw any indication that anyone billed for monitor reports ( my Medicare and secondary insurance cover those bills so I only get explanations of benefits showing what they paid) and I wondered if anyone was even checking those reports. I received a letter from the monitoring company after that informing me that they would be "-partnering" with my cardiologist for the remote reports. This meant that the company would do the "technical portion" ( reading, interpreting the data and sending a completed report to the cardiologist), and the cardiologist did the "professional component". So my insurance would be billed by this company (Cardionet) for the technical and the cardiology office for the "professional". And that's happened for a number of my remote monitor reports- seems the cardiology office doesn't miss a billing ( it's not much, I think they get about $28 or so). I've also seen bills from the company- they bill Medicare about $270 for that technical component but are only paid about $28. I haven't seen them bill for each monitor report, but I think they are very slow at it.

In any case, I'd think if you were getting those bills you'd expect to see two bills for each monitor report, one for the technical component and another from your physician for the professional component. Though if there is a pacemaker clinic staffed with enough personnel in your doctor's office to read and interpret your pacemaker data, and compile a report for your doctor, both bills might come from the office. 

Though why you aren't getting bills ( or explanations of benefits showing Medicare or supplemental insurance payment for those bills) is anyone's guess. It's possible if you contacted the billing department for your doctor's group they could enlighten you. 

billing thanks Marybird

by new to pace.... - 2022-04-06 00:11:24

I check my medicare site to see if there are new charges.  They do send me a monthly email if there are any new charges from any one.

That is why I know that the heart center has not billed Medicare for the remote transmissions.  it is not up to me to let  the heart center  know they are behind in their billing.  As you say they do not get much.  They really use those high charges as a write off.  am certainly not going to let them know they are behind 2 years  in their billing.

I did ask the cardiologist why they were not alerted the previous quarter when i had a long(2 hour) and high(224) Afib epidsode. Unlike this time of 10 minutes at 184 heart beats.  She was unable to answer.

New to Pace

by Good Dog - 2022-04-06 20:28:36

They are sent the reports on a quarterly basis (unless there is something amiss) which is pretty customary. I have that schedule and I get billed, but I send mine manually. Sounds like yours are sent automatically. I would certainly think that they would be billing for that service at least quarterly. I certainly don't blame you for not bringing it to their attention. Thing is: is anyone reviewing the reports? Did someone contact you when you had a 2 hr episode? In your comment it doesn't sound like it. If not, I have to wonder about the quality of your care. 

Remote Monitoring Bills

by Marybird - 2022-04-07 12:45:58

My providers bill for the remote monitoring of my pacemaker- my insurance ( Medicare and a secondary insurance) pays those bills and send me an explanation of benefits showing what's been paid. I can tell you though, with the number of people involved and the round robin processes they seem to use, I can't make heads or tails out of the dates of service listed on those report bills- those dates of service don't match the dates the 90 day routine monitor reports were sent. I'm thinking the dates of service on the bills may indicate when someone actually looked at the reports, wrote up a report ( for the technical portion of this bill) and the date that the cardiologist signed off on the report- these dates seem to be around 6 weeks after the reports were first sent, sooner if there was an alert.  My guess, anyway.

For about the first year I had the pacemaker, I had no idea when my remote monitor reports were sent, and got no bills either, so had to wonder if anyone was looking at them. I was told that reports were sent every 90 days, but without any feedback or bills, I figured all must be ok, but as you say, Good Dog,the question arises about whether there is actually a human being that looks at the things.

This changed for me with a change of personnel in the cardiology practice I go to. The EP left, the interventional cardiologist I had seen before the EP resumed my care, and they hired a cardiology monitoring company ( CardioNet) to review and evaluate their patients' cardiac implant reports, this company sends completed reports to the cardiologist. When I asked they gave me the scheduled dates for the wireless remote monitoring reports ( mine are automatic), and there have been several alerts from the monitor for mostly afib events. I've been contacted by the cardiologist's office when those alerts were actionable- twice for instructions to increase the metoprolol I take for rate control, and another time to come into the office to see the cardiologist to discuss the increased afib and start anticoagulation ( Eliquis). So I know they're monitoring things even though the billing times seem so squirrelly. Even still I am not so sure the cardiac monitoring company has billed for the technical component every time, but I figure that's up to them to figure out.

From what New To Pace has posted about her remote 90 day monitoring reports, and her providers providing the summary information from those on her patient portal at her request, as well as emails to her about abnormal findings on previous reports, it would seem the remote monitoring reports are received and reviewed. There may well be some billing issues that keep the practice from billing timely ( or at all) for that monitoring, but I'd tend to figure ( as I think NTP does), that it's up to them to figure that out. She mentions that she checks her Medicare information monthly ( that'd be online, they only send written explanation of benefit reports to Medicare recipients quarterly), so seems as though she's on top of who's reporting what in the way of billable healthcare measures to her Medicare account. Now who's reviewing her reports and when could be a matter of question, but I'd think the questions could be answered by asking the personnel in the cardiology, or pacemaker clinic. They should know

Guess what I'm saying is that not billing may raise questions about whether or not the service is provided, but doesn't necessarily mean the remote monitoring reports aren't evaluated by the providers.

 

remote transmission

by new to pace.... - 2022-04-07 15:12:17

I have Medtronic Carelink monitor.  I went on the Medtronic Carelink website and signed up to be notified  by email when the transmission was transmitted.  My healthcare surrogate  also signed  up and she recieves a text notification of the transmission..

I know at the heart center where i go, there has been many turnovers in help since the covid19 started.

new to pace

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I just want to share about the quality of life after my pacemaker, and hopefully increase awareness that lifestyles do not have to be drastically modified just because we are pacemaker recipients.