← Return to Medicare non coverage due to incorrect diagnostic code on claim

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@jennifer0726, thank you for sharing your experience. I'm a little confused, you said you had to pay out of pocket. What was the reason your private insurance denied the Vitamin D tests? I can see more why private insurance may deny nutrition classes, but what was the justification for denying a lab test ordered by a provider? Prior to going to our 4 month checkup, I had spoken to our nurse coordinator and asked her to verify all the labs were covered by Medicare. Well she checked all the labs(relating to blood draws) except for the 24 hour bp monitoring lab!!
You would think that since a provider is ordering the test it's medically necessary, right?

Yes, we also have good private insurance (Anthem employer group health plan)but it's secondary to Medicare because the 30 month coordination period has elapsed. The 3 tests that Medicare denied, due to not being medically necessary as coded, are Vitamin D, HgbA1c, and the ambulatory 24 hour blood pressure monitor tests all of which were pre-ordered months(they can't even track down the person put in the order!!) before the actual appointment. According to our post transplant nurse coordinator, all of these tests should have and would have been covered by Medicare, had the proper diagnostics were entered correctly at the time of order. Billing our work insurance was a whole separate issue that Mayo screwed up on. The policy for our work insurance is this: whatever Medicare covers the employer insurance will also cover. However, if Medicare does not cover a service, our employer insurance may still cover it depending whether it's a service that is covered under the employer insurance Summary Plan Description. But every time I have called Billing about this, its rep, including the lead of the group, would straight out say the secondary insurance will not cover a service when Medicare doesn't. This may be true for medigaps but it is not so when you have employer insurance as a secondary. Our employer insurance is another insurance(like when you have your employer insurance and your spouse has their own own and you're using your spouse's as a secondary insurance), it is NOT just a medigap. By federal law my husband has to be on Medicare for 36 months post transplant as required by his employer. If Anthem were primary, it would have covered those 3 tests listed above if the claims had been submitted to Anthem properly. Anyways, the point I'm trying to make is I don't know why Billing assumes that our secondary would not cover anything Medicare doesn't. So now, at this point I can get Mayo to correct the diagnostic codes and resubmit the claims to Medicare, or I can find out why the claims were not submitted properly to Anthem our secondary insurance. Both requires Mayo cooperation to resolve but I'm not having any luck. Personally, we feel that we have 2 insurance for a reason and we do not feel we should pay anything extras if the services are covered under our insurance plans. I have spoken to our nurse coordinator about this and she will provide any documentation necessary to correct the codes. We live in Calif and for the past 4 years, my husband sees a LOT of specialists and has LOTS of appointments and procedures done and we do NOT have any billing issues with any of his providers EXCEPT for Mayo Clinic Az!!! Apologize for ranting but I'm beyond frustration!!!

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Replies to "@jennifer0726, thank you for sharing your experience. I'm a little confused, you said you had to..."

Truly frustrating, @caretakermom. I hope you will call the Office of Patient Experience tomorrow during work hours. This is exactly the type of thing they can help resolve.

@caretakermom no need to apologize, I completely understand! I had my Transplant 12/7/20, at age 59, so my Medicare started 12/1/20. I am still in the first 30 months so my BCBS is primary and on 6/1/23 will switch to Medicare primary for 6 months. Then no Medicare until age 65. Is your husband under 65? I previously had been listed at U of Iowa and I believe the Vit D tests there were covered so it is a matter of coding. Now with Medicare secondary it seems I have to follow Medicare rules even before my private insurance is billed! I have been told that Medicare never covers Vit D tests. I pay the extra $170.10 monthly for Medicare and get very little benefit. Mayo is especially difficult to get them to re-bill with correct coding and they told me the same thing about they weren’t the ones who ordered the tests. I had high blood calcium and the insurance didn’t want to pay that test and Vit D due to coding. That is I why I had to pay those bills out of pocket. I think it boils down to standard orders in place that are not specific to us individually for set follow up visits. Mayo Specialty Pharmacy has billed me twice as much as my private copay in the early months of the year and it is primary! (they say they have to bill the Medicare deductible up front even though my private co-pay is only $10) Then recently found they stopped billing Medicare as secondary on one of my tx meds like 6 months ago. I get frustrated and sometimes give up on making sure it is done right at Mayo because I am SO grateful for my living transplant & bi-lateral nephrectomy. Your experience with getting billing errors fixed at other providers being easier is the same for me. I dread the Medicare switch the final 6 months and then it stopping until age 65-all my providers billing people will be confused! Your husband is lucky to have you to advocate for him! I am thankful to have someone who can relate to the billing issues.