Medicare non coverage due to incorrect diagnostic code on claim

Posted by caretakermom @caretakermom, Sep 4 6:30pm

Hi everyone,
My husband is about 6 months post kidney transplant which he received from Mayo Clinic Az. He has Medicare as his primary and employment insurance as secondary. Thus far, there are 3 lab tests that Medicare denied coverage and for which he did sign ABNs. Medicare denied coverage because the code submitted on the claims did not indicate medical necessity(even though these tests were standard tests ordered for post transplant patients). Upon closer scrutiny, I discovered that the labs were originally ordered with the wrong codes, codes that are too general to convey specific medical conditions. Unfortunately, our nurse coordinator says these tests were ordered months ago, and neither she nor her staff ordered them. Apparently, the order was put into the system by another department and these are all standard orders for post kidney transplant patients.
I'm having a devil of a time getting Mayo to correct these codes, no one seems to know what is the proper procedure and which department is responsible to make the change. I have called billing many times and they say they cannot make any changes. They directed me to the Records and Amendment Dept and the lady there says she's not the one to make the change either. The nurse tried to do it via the patient chart on Epic but the changes she put in got reversed overnight by the software. So Epic is not updating it either for whatever reason(probably due to IT issues). I have spoken with the provider office(nurse coordinator) she gave me the corrected ICD-10 codes to use for the non covered claims but I'm unable to find anyone at Mayo who can help me resolve this issue. Just FYI, billing is inert because they go by what is on the original order. Does anyone have any idea who I can call for help? Is there a patient advocacy program I can talk to? I just don't understand why they can't make changes to the codes, even though we have support from the provider office. Error in coding happens often and there should be a way to resolve!! Suggestions/advice welcome. Looking forward to hearing from you!!

Interested in more discussions like this? Go to the Transplants group.

@caretakermom Contact the Office of Patient Experience at Mayo Clinic Office of Patient Experience
Phone: 844-544-0036 (toll free)

I'll bet they can help you! Good luck and please let me know everything turns out okay.
Ginger

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@caretakermom, I agree with @gingerw. You've done enough running around in circles. I recommend you contact Mayo Clinic's Office of Patient Experience. They will help mediate the issue and get you to the right person to correct the error. https://www.mayoclinic.org/about-mayo-clinic/patient-experience

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@gingerw, @colleenyoung, thank you for chiming in. Indeed I have been getting the run around since May and the issue is still not resolved. I will contact Patient Experience and hope they can direct me to the proper dept to handle this. I will post back after if I get any updates! Thank you!

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@caretakermom

@gingerw, @colleenyoung, thank you for chiming in. Indeed I have been getting the run around since May and the issue is still not resolved. I will contact Patient Experience and hope they can direct me to the proper dept to handle this. I will post back after if I get any updates! Thank you!

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Hi @caretakermon,
I had the same experience at Mayo Rochester with billing for Vitamin D tests and nutrition class and nutrition one on one. I have good private insurance plus Medicare secondary. I ended up paying the bills, but decline having vitamin D tests now when I can. It seems they put in a standard lab order for visits like the 4 month, 1 year, etc. and it is hard to decline those even if I request it ahead of time. It is tricky though, because I do not want to appear “non-compliant”. It is frustrating when as you said it is a matter of changing the coding. Please do share if you are able to find a way to resolve it. -Jennifer

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@jennifer0726

Hi @caretakermon,
I had the same experience at Mayo Rochester with billing for Vitamin D tests and nutrition class and nutrition one on one. I have good private insurance plus Medicare secondary. I ended up paying the bills, but decline having vitamin D tests now when I can. It seems they put in a standard lab order for visits like the 4 month, 1 year, etc. and it is hard to decline those even if I request it ahead of time. It is tricky though, because I do not want to appear “non-compliant”. It is frustrating when as you said it is a matter of changing the coding. Please do share if you are able to find a way to resolve it. -Jennifer

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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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@caretakermom

@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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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.

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@caretakermom

@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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@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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@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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@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.

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I am not a Mayo Clinic patient, but like @jennifer0726 and @caretakermom I have had issues when wrong codes are entered into a computer for billing purposes. Recently this happened with orders sent in to the lab from a specialist. Fortunately, the phlebotomist saw it, gave me a printout and told me she was going to look into it, and get the codes changed right away. This same gal has called the drs before, as I was there, to get things corrected. Very lucky to have her so knowledgeable and in my corner!

Healthcare staff are so overworked these days, I think we are lucky there are not more issues!
Ginger

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Hi @caretakermom, I did not have 24 hour ambulatory BP monitoring at my 4 or 12 mo. visits. My BP is usually good. I live out of state, too, in IA and tx in MN. I had a pre-emptive living donor tx, and didn’t do dialysis thankfully. Billing errors can happen for anyone, but usually for me now and over the years at local providers I can get them resolved.
@gingerw It is great that your phlebotomist is so aware and caught those wrong codes!
My main local lab is where they told me Medicare never pays for Vit D etc. tests and wanted me to sign a waiver saying I would pay full price! I didn’t because they had a contractual relationship with BCBS and are required to accept what they determine my co-pay or co-insurance to be unless it is a non covered charge. I also plan to work past 65 if I am able, as I prefer to be able to keep my private insurance and it will increase my future pension. I took Medicare A & B as I was told if I didn’t they wouldn’t cover the tx meds after I turn 65 under part B. I still pay my BCBS premiums, deductible & co-pays/co-ins, too. Cost of living in IA is much less than CA, and my income is most likely way less and that is why I pay the basic $170.10 per mo. Medicare premium for part B. For me, it is expensive on top of everything else being single. I am thankful to work for the State and to have good benefits. I hope you can get your coding issue solved!

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@jennifer0726

Hi @caretakermom, I did not have 24 hour ambulatory BP monitoring at my 4 or 12 mo. visits. My BP is usually good. I live out of state, too, in IA and tx in MN. I had a pre-emptive living donor tx, and didn’t do dialysis thankfully. Billing errors can happen for anyone, but usually for me now and over the years at local providers I can get them resolved.
@gingerw It is great that your phlebotomist is so aware and caught those wrong codes!
My main local lab is where they told me Medicare never pays for Vit D etc. tests and wanted me to sign a waiver saying I would pay full price! I didn’t because they had a contractual relationship with BCBS and are required to accept what they determine my co-pay or co-insurance to be unless it is a non covered charge. I also plan to work past 65 if I am able, as I prefer to be able to keep my private insurance and it will increase my future pension. I took Medicare A & B as I was told if I didn’t they wouldn’t cover the tx meds after I turn 65 under part B. I still pay my BCBS premiums, deductible & co-pays/co-ins, too. Cost of living in IA is much less than CA, and my income is most likely way less and that is why I pay the basic $170.10 per mo. Medicare premium for part B. For me, it is expensive on top of everything else being single. I am thankful to work for the State and to have good benefits. I hope you can get your coding issue solved!

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Hi @jennifer0726, the ambulatory 24 hr bp monitoring test is a standard test Mayo Az orders for all patients in their 4 month post kidney txplant follow up which includes a biopsy. As I understand it, the 1 and 2 year follow up are similar to the 4 month follow up. So you are probably lucky your Mayo team didn't order one for you. All of the coding issues/Medicare non coverages we have incurred thus far(this is hubby's 2nd year on Medicare) are with the Mayo Az campus and they stem from labs that were ordered by the Mayo Az providers and done at Mayo Az. We were not told ahead of time whether a test is optional so when we show up for labs, we just assume it's medically necessary. By virtue of the Mayo provider ordering these labs, you would think the they are medically necessary!! You are right in that coding errors wrt to Medicare occurs often and it is not unusual for providers to make corrections. But for some reason it's is extremely difficult to make code corrections with Mayo Az, even when you have the provider's support to make the coding change!!! Thanks for your input!

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