Hi @hello1234, thank you for your input and I will keep the Medicare Coordination Benefits Dept number. It is always nice to be able to speak with Medicare specialist with expertise with ESRD.
Your situation is a little different than hubby's. You applied for Medicare AFTER your kidney transplant and you are only Medicare eligible for 3 years post transplant. Hence, your 30 month coordination period started after your kidney transplant, with your employer insurance as primary and Medicare secondary. However, after your 30 months coordination of benefit period is over, the roles switch with Medicare being primary and employer insurance as secondary. I'm not sure what the policy of your employer was but with most employer, if the employee is Medicare eligible the employer is going to mandate him/her to get Medicare. So after the 30 month coordination period, Medicare is not an option it has to be primary!
My hubby was eligible to apply for Medicare when he was first diagnosed with ESRD. At that time, he started dialysis but didn't have to apply for Medicare right away because he had (and still has) employer insurance. But he chose to apply for Medicare immediately because he was not sure if he was going to be able to continue to work. Medicare was not mandatory then(per his employer) until the 30-month coordination period is over, starting from the month he was diagnosed as ESRD. So in the period since he applied for Medicare, the first 30 months is the employer insurance as primary and Medicare as secondary. Then after the 30 month coordination period, Medicare becomes primary and the employer insurance is secondary. His 30 month coordination period ended on May 2022 so it is now Medicare primary and employer insurance secondary. There is no way to choose to have Medicare as secondary now. It's mandatory that Medicare is primary until he is no longer Medicare eligible!
We don't have any billing issues with our local providers. Every one of his providers file their claims properly with Anthem BCBS and all these claims show up as in-network. Mayo Clinic Az is THE ONLY provider that is filing claims that are showing as out-of-network in our Anthem BCBS account. I think the issue may have to do with the fact that they are out of state provider for us. And if the providers are out of state, they're supposed to file the claims with the blue office that is LOCAL TO THE PROVIDERS. I'm not sure where Mayo Billing is sending the claims but if they send them to the L. A. office, then the claims won't get paid because they are not responsible to pay out claims for services sought outside of California. The claims must go thru the provider's local blue office which is responsible for payment. It specifically says this on the back of our Anthem BCBS card. Hubby's insurance can be used anywhere in the U.S, not just restricted to our state!
I've made this known to Mayo Billing and their response is that it's up to our insurance to decide whether they should process the claims as in network or out of network!! The reality is that providers should know which insurance carriers they are contracted with and thus file the claims accordingly. The Mayo website shows our employer insurance is in-network and Anthem also shows that they are in network so there is no confusion there. But yet, Mayo billing is filing claims as out of network, according to Anthem. If the provider doesn't process the claims properly(like not sending it to the PROVIDER's local BLUE office) then the claims won't get paid and will be treated as out of network! But yet Mayo Billing says it's up to Anthem how the claims should be processed!! And Anthem is telling us that Mayo has to process the claims properly. It's like Mayo Billing doesn't want to take any responsibility that they may NOT be processing the claims properly and they want to want to put all the responsibility on Anthem.
Why did Mayo billing not inform us that Anthem BCBS is out of network during insurance verification prior to transplant, if it is indeed out of network? I think it boils down to the Mayo Billing staff not understanding how to work with Medicare and employer insurance. BTW, hubby's employer insurance is a regular insurance policy with him being the subscriber and I as his spouse is the dependent. It is NOT A SUPPLEMENT!! It is more like a complement insurance, it will cover whatever the primary doesn't, subject to the employer plan's deductible and out-of-pocket.