Does medicare deny services?

[dkf]

Educate me please.

[CC]

1. Not that I've ever

heard of.

[pinto]

2. Like all health care payment programs, Medicare doesn't cover some things, limits reimbursement

for some others, and as an overall standard - covers 80% of "usual and customary" fees.

That said - I've been a Medicare recipient for years, have never found it to be a big impediment to getting timely, quality health care.

My only beef would be dental care. That's always a struggle.

[dkf]

3. I'd be interested to see a comparison of requests, denials, and cost coverage

It all seems so non-transparent to me. I don't know how we the public are supposed to figure out what is a good idea and what isn't.

[alsame]

7. Dental is my mother's only complaint also. Otherwise, she's been

very pleased with her Medicare coverage for over 10 years. She's never been denied anything that a Dr requested.

[HillbillyBob]

14. Same here with the dental

nt

[WePurrsevere]

15. I agree. I've been on Medicare for..

18 yrs. I have a few beefs with them most of my experience has been positive.

Lke you dental is a BIG one and dental health is extremely important not just to ones emotional well being but to our physical health.

One of my other BIG beefs is that those of us who are mobility/energy impaired can't get an electric wheelchair/scooter unless we need it for inside our home. If we can get around inside our home without one we can't get one. I need it so I can enjoy festivals/fairs, farmers markets, flea markets, shopping in many stores, etc. It's a physical challenge to enjoy going somewhere that doesn't have scooters available to their customers as a courtesy so I've had to cut way back on doing things I used to enjoy. From what I understand to get one for work would be different procedure... many years ago when I was still sort of able to work a bit I was offered help to get one by vocational rehab. If I knew then what I know now.. I'd have taken them up on the offer. :(

Another is routine health exams as has been mentioned. I wait until I have something really wrong to go.

[Justitia]

4. It has well known parameters that health providers work within.

My son has had Medicare for the last 3 yrs and a boatload of medical problems, services.

He just had a kidney transplant via Medicare.

We have never been "denied" any svc from Medicare.

Now, Medicare does have limits, parameters, "usual fee" structures, but the docs & hospitals work within those limits.

But, if I understand your question....something like if my son went in for an MRI, would Medicare bounce back and say "not covered"?
That has NEVER happened to us.

Is that what you mean?

[dkf]

9. Kind of. But it seems in some cases, procedures aren't even approved to be performed.

But is this the hospital's denial or the insurance company's denial? If Natalie Sarkasian's family had promised to pay the funds early on, would they have done it? Or did the hospital decide they wouldn't take the chance on the family's ability to pay? Where is the break down exactly?

[Justitia]

18. In my son's transplant case, the hospital submitted a request for transplant to Medicare.

Medicare gave approval and we got the green light to proceed.

I think any hospital would at least put through a request to Medicare for review - on a Medicare eligible case.

There were certain parameters to his transplant though - usually cannot have cancer, cannot be a drug abuser, etc.
These are really about the physical viability of the transplant & scarcity of organs.
In all the cases that I personally know of, all potential candidates had no problem meeting those requirements.

I have no idea as to whether Medicare would consider her specific type of transplant "experimental", but my personal experience is that Medicare defers to doctors opinions on medical necessity.

It appeals to my common sense that Medicare would have been way better on her case than a "for profit" company that would increase shareholder value by denying her expensive care.

[andym]

5. Yes-- they have rules to determine what they will pay for and when n/t

[Bluerthanblue]

6. yes they do-

they also set limits on procedures-

There is an appeals process, but it can prove too difficult for some, too late for others.


It isn't a perfect system. But it's a hell of a lot better than nothing.

[dkf]

12. How's about in life or death situations though?

I can see for a little procedure or checkup they might want a person to pay for everything, but do they ever deny care which they know will result in death for something that is not very close to being terminal?

[FarCenter]

8. Routine physical exams are not covered, for example, only the first at age 65

Physical Exams (routine) ( one-time “Welcome to Medicare” physical exam)

Medicare Part B covers a one-time “Welcome to Medicare” physical exam, which includes a review of your health, as well as education and counseling about the preventive services you need, including certain screenings and shots. Referrals for other care, if you need it, may also be included. Medicare doesn’t cover routine physical exams.Important: You must have the physical exam within the fi rst 12 months you have Medicare Part B. Th e Part B deductible doesn’t apply. In 2008 YOU pay 100% for most routine physical exams, in general.You pay 20% of the Medicare-approved amount for the “Welcome to Medicare” physical exam.

From http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf "Your Medicare Benefits"

Another example is an eye exam. The exam is covered, but the "refraction" to determine a corrective lens prescription is not.

[FarCenter]

13. Medicare Part C (Medicare Advantage) may offer more/different coverage

And your Medigap or other secondary insurance may cover the copays or the things that Medicare Parts A&B do not.

[begin_within]

10. They don't pay for long-term care, such as a nursing home.

They pay for acute care in a Skilled Nursing Facility, for up to 100 days per illness. And they only pay 100% of the costs for the first 20 days of the stay. From day 21 to day 100, there is a patient copayment (currently $128 per day). But after that 100 days runs out you're totally on your own if you have to continue to stay in the facility. And there are other requirements such as a doctor's statement that you continue to need the skilled nursing such as physical therapy, occupational therapy, speech therapy, nurse services, etc. Medicare will not pay for long-term custodial care of any patient.
Medicare will sometimes not pay for "off-label" uses of a prescription drug. If a doctor prescribes a certain drug, for a condition that is not on the official FDA list of conditions approved for treatment by that drug, Medicare will probably not pay for the drug, and if the patient still wants to use it they will have to pay the full out-of-pocket costs.

[HillbillyBob]

11. They will deny elective or cosmetic services unless its something like

really bad scaring from burns or something.
I have been Medicare /Medicaid client for about 15 years, if it was medically necessary a good dr will put it through that way.
I have only been denied surgery for deviated septum, which leads to a lot of sinus infection, they saw it as unnecessary/cosmetic, even though it would not make any difference in how I look, but sure would make a difference in how I breath and cut down on sinus headaches.

I have had a stent put in my heart artery after a heart attack, bypass in my femoral artery, cancer surgery 3x and have been hiv+ for years.

If my health insurance had not dumped me when I had pnuemocystis pneumonia I would likely still be working, but since they did that I landed homeless and out of work and sick up to the point where I ended up in ICU without medicaid and medicare I would be dead by now, no thanks to bcbs.

[Emit]

16. Here are some common services not covered by Medicare

Long Term custodial care (nursing home)

Private hospital room (unless determined to be medically necessary), telephone and television

Private duty nursing

First 3 pints of blood, if you cannot replace them in some manner

Routine physical care, other than the "Welcome to Medicare" one time physical exam

Dental care and dentures

Routine hearing exams and hearing aids

Routine eye exams and eyeglasses, except cataract lenses (routine eye exams for individuals with medical conditions which affect sight may be covered)

All over-the-counter drugs

Routine podiatry care (care for persons with certain medical conditions, such as diabetes or vascular heart disease, may be covered)

Inpatient psychiatric care, after 190 days (lifetime limit)

Acupuncture, and most chiropractic services

Cosmetic surgery, unless after injury or to improve the function of a malformed body part

Full-time home care, homemaker services, home-delivered meals

Christian Science practitioners and Naturopath's services

Orthopedic shoes, unless part of a leg brace and included in orthopedist's charges or vascular or nerve defects due to diabetes.

Ambulance services unless medically necessary

Services provided outside the United States (except for certain hospital and physician services in Canada or Mexico, under certain conditions)

http://www.medicarehelp.org/MedicareHelp/Services_Not_Covered.htm
http://www.medicarehelp.org/index.html

[dkf]

17. I'm wondering more about life threatening denials.

[ejpoeta]

19. i've seen a couple posts on here that suggest the medicare advantage might.

something about kaiser permanente. i doubt they are supposed to, but i would believe that the private insurance aspect would try to limit having to pay for things.

[Creena]

20. Yes and No.

Medicare would not pay for a fully electric hospital bed for my mom, so she pays $50/month out of pocket.

Also, there are different levels of mattress overlays: Egg Crate (EC), Gel, Alternating Pressure (AP), and LAL (Low Air Loss). Medicare will not cover an overly as a preventative measure; only if skin degradation is shown. Even then, the lower stage of ulcer, the lower level of overlay.

When I hurt my back and couldn't turn my mom on a daily basis, she received an AP overlay due to pressure sores. Now, she actually just has a mattress because it works out better during bed baths.

Edit: Oh, you're looking for life threatening denials. Luckily, I have not found myself in that boat.

[dkf]

23. You are so good to take care of your Mom.

It sounds like you did a lot of research to help her feel comfortable. She is very lucky. :)

[marybourg]

21. Yes. Everything must be "medically necessary". They once

denied a claim for a blood clotting test while my husband was getting knee surgery because they stated (wrongly) that he had never had a blood clot, therefore the test was not "medically necessary". The hospital wound up eating it. But put in perspective, this was the only irritation in 18 years.

[jwirr]

22. Some services from both Medicaid and Medicare have to be approved

before they can be given. That said, if they are justified they are not denied.