06111945ccc, I haven't been to lab corp. Babs10's (Thank you Babs) experience may be the answer. Your original Medicare does pay. It is the Advantage Plans that are disadvantaged. It might be that your physician has more sports patients than osteoporosis patients (aside from being young enough not to know the ropes). If you have been denied payment by medicare, there is an appeals process. I'd hand the entire mess to the billing staff at your physician's office. You might have to direct them to the statement of medical necessity. You are covered.
Does anyone know of MDs that rx for these lab tests in Wisconsin or norther Illinois? I have standard Medicare and have osteopenia. I want to avoid any injectables in the future.
06111945ccc, I haven't been to lab corp. Babs10's (Thank you Babs) experience may be the answer. Your original Medicare does pay. It is the Advantage Plans that are disadvantaged. It might be that your physician has more sports patients than osteoporosis patients (aside from being young enough not to know the ropes). If you have been denied payment by medicare, there is an appeals process. I'd hand the entire mess to the billing staff at your physician's office. You might have to direct them to the statement of medical necessity. You are covered.
@cat1203, thanks for your post.
There are areas where this doesn't apply, the most obvious and most preclusive is the inability to choose your doctors.
If a person's physician doesn't (isn't willing to) include a medical necessity indication on their requisition for coverage of bone markers, they aren't approved with original or advantage medicare plans.
There is an advantage to the insurer to include physicians in their plans. Delay is often denial. Preapproval can be defacto denial.
@cat1203, thanks for your post.
There are areas where this doesn't apply, the most obvious and most preclusive is the inability to choose your doctors.
If a person's physician doesn't (isn't willing to) include a medical necessity indication on their requisition for coverage of bone markers, they aren't approved with original or advantage medicare plans.
There is an advantage to the insurer to include physicians in their plans. Delay is often denial. Preapproval can be defacto denial.
@gently True, MA HMOs require you to choose only doctors in your plan's network. But all plans must cover all medically necessary services that Original Medicare covers, as is stated plainly on Medicare.gov. My rheum ordered bone markers for me at my request even though they don't use them to guide clinical treatment so I got no useful info from my rheum re: the results in comparison to the bone markers I ordered and paid for myself prior to treatment on Forteo, and relied on information in this support group and elsewhere to interpret. My insurance did pay for the bone markers when my doctor ordered them. Whether my rheum indicated it was a medical necessity I can't say; I didn't ask them to and no longer have the order to refer to. But if it's true that neither OM or MA will pay for bone markers unless the ordering doctor says its a medical necessity, then in that respect there is no difference between OM and MA and no advantage to OM over MA. Yes, MA plans often require pre-approval for things whereas OM rarely does. That, like the network restrictions, is a difference in how OM and MA are administered. It is not a difference in coverage. If you want to say that having to get pre-approval in effect equals no coverage if it is delayed or denied, of course I respect your right to that opinion. But I'm curious, when OM denies claims, do you also regard that as not providing coverage? I've had both OM and MA, BTW. On OM I once had routine blood work denied that I had to fight to get them to pay for that was more time-consuming and frustrating than any PA. which has actually largely gone smoothly for me. In the end I am not trying to champion one over the other, however.
@gently True, MA HMOs require you to choose only doctors in your plan's network. But all plans must cover all medically necessary services that Original Medicare covers, as is stated plainly on Medicare.gov. My rheum ordered bone markers for me at my request even though they don't use them to guide clinical treatment so I got no useful info from my rheum re: the results in comparison to the bone markers I ordered and paid for myself prior to treatment on Forteo, and relied on information in this support group and elsewhere to interpret. My insurance did pay for the bone markers when my doctor ordered them. Whether my rheum indicated it was a medical necessity I can't say; I didn't ask them to and no longer have the order to refer to. But if it's true that neither OM or MA will pay for bone markers unless the ordering doctor says its a medical necessity, then in that respect there is no difference between OM and MA and no advantage to OM over MA. Yes, MA plans often require pre-approval for things whereas OM rarely does. That, like the network restrictions, is a difference in how OM and MA are administered. It is not a difference in coverage. If you want to say that having to get pre-approval in effect equals no coverage if it is delayed or denied, of course I respect your right to that opinion. But I'm curious, when OM denies claims, do you also regard that as not providing coverage? I've had both OM and MA, BTW. On OM I once had routine blood work denied that I had to fight to get them to pay for that was more time-consuming and frustrating than any PA. which has actually largely gone smoothly for me. In the end I am not trying to champion one over the other, however.
@cat1203
" Medicare Advantage plans denied prior authorization requests and payment requests that met Medicare coverage and billing rules by 1) using internal criteria that are not contained in the Medicare coverage rules; 2) requesting unnecessary documentation although appropriate documentation was found in patient records submitted by physicians; and 3) making manual review errors and system errors."
Delay is equivalent to denial when a patient dies or is not longer eligible for the service that would have been provided.
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06111945ccc, I haven't been to lab corp. Babs10's (Thank you Babs) experience may be the answer. Your original Medicare does pay. It is the Advantage Plans that are disadvantaged. It might be that your physician has more sports patients than osteoporosis patients (aside from being young enough not to know the ropes). If you have been denied payment by medicare, there is an appeals process. I'd hand the entire mess to the billing staff at your physician's office. You might have to direct them to the statement of medical necessity. You are covered.
Labcorp, but I've also used Quest.
Thanks to all who helped me.
Resolution came when I was given the phone number for Lab Corp customer service (888) 210-9264.
Lab Corp received my doctor‘s letter of medical necessity but never forwarded it to Medicare.
Blessings,
cc
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2 ReactionsDoes anyone know of MDs that rx for these lab tests in Wisconsin or norther Illinois? I have standard Medicare and have osteopenia. I want to avoid any injectables in the future.
@gently Medicare Advantage has to cover everything that OM does.
@cat1203, thanks for your post.
There are areas where this doesn't apply, the most obvious and most preclusive is the inability to choose your doctors.
If a person's physician doesn't (isn't willing to) include a medical necessity indication on their requisition for coverage of bone markers, they aren't approved with original or advantage medicare plans.
There is an advantage to the insurer to include physicians in their plans. Delay is often denial. Preapproval can be defacto denial.
@gently True, MA HMOs require you to choose only doctors in your plan's network. But all plans must cover all medically necessary services that Original Medicare covers, as is stated plainly on Medicare.gov. My rheum ordered bone markers for me at my request even though they don't use them to guide clinical treatment so I got no useful info from my rheum re: the results in comparison to the bone markers I ordered and paid for myself prior to treatment on Forteo, and relied on information in this support group and elsewhere to interpret. My insurance did pay for the bone markers when my doctor ordered them. Whether my rheum indicated it was a medical necessity I can't say; I didn't ask them to and no longer have the order to refer to. But if it's true that neither OM or MA will pay for bone markers unless the ordering doctor says its a medical necessity, then in that respect there is no difference between OM and MA and no advantage to OM over MA. Yes, MA plans often require pre-approval for things whereas OM rarely does. That, like the network restrictions, is a difference in how OM and MA are administered. It is not a difference in coverage. If you want to say that having to get pre-approval in effect equals no coverage if it is delayed or denied, of course I respect your right to that opinion. But I'm curious, when OM denies claims, do you also regard that as not providing coverage? I've had both OM and MA, BTW. On OM I once had routine blood work denied that I had to fight to get them to pay for that was more time-consuming and frustrating than any PA. which has actually largely gone smoothly for me. In the end I am not trying to champion one over the other, however.
@cat1203
" Medicare Advantage plans denied prior authorization requests and payment requests that met Medicare coverage and billing rules by 1) using internal criteria that are not contained in the Medicare coverage rules; 2) requesting unnecessary documentation although appropriate documentation was found in patient records submitted by physicians; and 3) making manual review errors and system errors."
Delay is equivalent to denial when a patient dies or is not longer eligible for the service that would have been provided.