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

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@jennifer0726

@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.

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Replies to "@caretakermom no need to apologize, I completely understand! I had my Transplant 12/7/20, at age 59,..."

@jennifer0726, my husband was on dialysis at the age of 59 so at that time he had already applied for Medicare, even though our employer insurance would have been sufficient until the 30 months coordination benefits expires. But we applied for Medicare at the get go because we have been advised by a dialysis counselor that if you delay enrollment in Medicare when your eligible you may be subject to a penalty when you apply for it later . So we erred on the safe side and applied for Medicare as soon as my husband was diagnosed with ESRD. He was on dialysis for 3 years before Mayo called him that a organ was available on 3/12/22. By that time the 30 month coordination period has already expired and he had and still does have Medicare as primary and Anthem PPO as secondary. He will continue to have Medicare until just after he turns 65, 36 months after his txplant from 3/12/2022. But our plan is for him to continue to work past 65 if he is still able. This means he will have to pause Medicare at the end of the 36 months post transplant(because his employer ins would be primary and Medicare being secondary is pretty much useless) and pick it up again when he does retire at age 70 hopefully. We have a lot of medical bills to deal with and it makes more sense for him to continue to work so that he can get the medical/dental/vision/Rx benefits. We have never had billing issues with our Calif providers until txplant at Mayo Az!! I'm thinking it's because they are out of state??
We have been paying about $800 plus every quarter for just Medicare B(no part D) since Nov 2018. And you're right you do not get much from it when it's secondary, only pays off when Medicare is the only insurance you have. If we have/had a choice we would have chosen to remain with Anthem as our primary but they have a rule in the SDP that says ESRD patients have to switch over to Medicare after 30 months. Even though we pay for Medicare Part B, we also have to pay for the employer insurance premium at the full price, no discount offered even with Medicare as primary. Still have to meet the yearly deductibles and out of pockets($2000.00 per member, $3000.00 per family), etc just like any "regular" insurance, like it was prior to having Medicare in the mix.
As far as Vitamin D test goes, it is NOT our experience that Medicare does not cover. Medicare will cover it if the correct diagnostic code is submitted(confirmed by our nurse coordinator there is a more specific code for patients such as my husband). Furthermore, the 3 years my husband was on dialysis(home hemo dialysis and I gave him treatment 5x/wk), he was allowed 1 vitamin D lab test per year, paid for by Medicare(as well as our employment ins when it was primary). Did you have the ambulatory 24 hour bp monitoring test on your 4 month checkup? Did your insurance cover it?
I too am glad there is someone out there who understands what we're going thru. Thought were was the only ones with this issue… I'm sorry you were not able to resolve your billing issues with Mayo. I'm hoping it will go better with us.