Providers Extracting Extra Money from SecureHorizons Members

[allhealthandlife]

I had a customer switch from SecureHorizon's PPO to another plan because he said his co pay to his dermatologist for burning skin cells of his face was $ 30.00 plus 20% of the "out patient surgical services " charge which amounted to over 200.00 for each visit.I told him that this doesn't sound right and did a three way call to SH claims with him and discovered that the doctors office never submitted a claim for an outpatient services -only for office visits.Of course the reason the doctors office didn't submit the surgical claim is that UHC would have not paid it because the " surgery " was done the doctors office and wasn't a valid charge according to their contract.I have discovered this type of extra billing for 20% of outpatient services occuring with other specialist as well.( especially for a colonoscopy which is suppose to be 0 co pay for a preventative)Usually the customers are asked to pay these fees up front too. I am kind of surprised that a doctors office does this routinely and expects to get away with it.If they are not happy with what a plan pays for services they shouldn't accept the plan and not try to extract extra money from patients to make up the difference.This bill padding seems to happen more with the MA PPO's than HMO's

Hopefully the doctors office will get a little worried when this patient goes to the doctor's office Monday and demand a written detail of all charges that he can compare to what was actually submitted to claims by the doctor.

 

[Josh]

With any due respect, I don't think you know what you're talking about. SecureHorizons is a lousy plan to begin with. It doesn't matter where a surgery is performed, it's considered an outpatient surgery. Same thing with the colonoscopy. Usually they will only pay for a colorectal screening which IS different from a colonoscopy. A colonoscopy is considered surgery and would pay at the outpatient surgery benefit amount.

Doctors are asking for fees upfront because they spend a fortune trying to collect if they don't get it upfront.

Again, with any due respect, I think it has more to do with your unfamiliarity with the way the system works rather than the second largest health insurer in the company getting away with ripping clients off that way.

 

[allhealthandlife]

With any due respect, I don't think you know what you're talking about. SecureHorizons is a lousy plan to begin with. It doesn't matter where a surgery is performed, it's considered an outpatient surgery. Same thing with the colonoscopy. Usually they will only pay for a colorectal screening which IS different from a colonoscopy. A colonoscopy is considered surgery and would pay at the outpatient surgery benefit amount.

Doctors are asking for fees upfront because they spend a fortune trying to collect if they don't get it upfront.

Again, with any due respect, I think it has more to do with your unfamiliarity with the way the system works rather than the second largest health insurer in the company getting away with ripping clients off that way.

I have been selling Medicare insurance since 1992 with over 1000 Med Supps and over 3000 MA under my belt.I did over 170 enrollments for SecureHorizon's last AEP (I believe I was in the top five in Florida) so I do believe I know a little bit about how the system works especially SecureHorizons.

Not saying that MA isn't flawed but my point was that I have witnessed doctors overcharging SecureHorizon members.If they were not doing anything wrong here why would the doctor not submit the extra 1200.00 " outpatient surgery charge " to UHC to collect the other 80% ? The reason is that a simple removal of skin cancer in a doctors office is usually covered under the OV charge.Do you think original Medicare would allow a total of $ 1400.00 for a visit to a dermatologist for a skin lesion removal .

BTW if you have been in the industry for a while I am sure you know the MA have to pay by the same guidelines as Medicare and when it comes to colonoscopy a preventive screening (including colonoscopy) it is covered once every ten years for the general population on Medicare and once every five years for high risk patients.Don't take my word for it's on page 28 of the Medicare and you Handbook( see below).This is a great resource for Medicare 101 stuff like this.The local colecteral screening center here in North Florida is hitting members up for extra " facility " and "outpatient service charges " which they collect up front but many times these charges are never submitted to UHC and no detail ever mailed to patients.Sounds fishy to me.


Colorectal Cancer Screenings
To help find precancerous growths and help prevent or find cancer early, when treatment is most effective. One or more of the following tests may be covered. Talk to your doctor.
Fecal Occult Blood Test—Once every 12 months if age 50 or ■■older. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.
Flexible Sigmoidoscopy—Generally, once every 48 months ■■if age 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. You pay 20% of the Medicare-approved amount.
Colonoscopy—Generally once every 120 months (high risk ■■every 24 months) or 48 months after a previous flexible sigmoidoscopy. No minimum age. You pay 20% of the Medicare-approved amount.
Barium Enema—Once every 48 months if age 50 or older (high ■■risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare-approved amount.
Note: If you get a screening flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare-approved amount

 

[Josh]

Not saying that MA isn't flawed but my point was that I have witnessed doctors overcharging SecureHorizon members.If they were not doing anything wrong here why would the doctor not submit the extra 1200.00 " outpatient surgery charge " to UHC to collect the other 80% ? The reason is that a simple removal of skin cancer in a doctors office is usually covered under the OV charge.Do you think original Medicare would allow a total of $ 1400.00 for a visit to a dermatologist for a skin lesion removal .

The short answer is, I do believe Medicare would allow a charge like that. Each case like this would have to be looked at individually, but Original Medicare will pay crazy amounts for services not rendered, not medically necessary, or overbilled, they have a history of that. In fact, that's one of the arguments MA companies use to justify their existence.
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The local colecteral screening center here in North Florida is hitting members up for extra " facility " and "outpatient service charges " which they collect up front but many times these charges are never submitted to UHC and no detail ever mailed to patients.Sounds fishy to me.

I'm not disagreeing that it sounds fishy, but it could very well be completely legitimate. At the end of the day the medical industry is a business and businesses can chose to bill for things differently. The colorectal screening itself may very well be covered 100% by Medicare, but there may also be an office visit charge. Think about when someone goes in for a chemo treatment, chemo is covered by part b (with original Medicare) and the office visit is billed as a separate charge. Same thing with lab work, patient goes into a doctor to have lab work, doctor draws blood and send it to the lab. Lab visits are covered separate from the office charge. Sometimes a doctor won't charge for this if it's part of a visit OR if they can bill for the labwork themselves, but it doesn't mean they're "extracting extra money from ... members" or scamming them if they see the extra charge.

The removal of a skin lesion is roughly the same thing. The doctor can just slice it off and bill for an office charge OR bill it as outpatient surgery (which is what it is). Sometimes a doctor will not bill it as a surgery to Medicare patients as a courtesy, but billing it out as surgery is what they're rightfully entitled too.
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I have been selling Medicare insurance since 1992 with over 1000 Med Supps and over 3000 MA under my belt.I did over 170 enrollments for SecureHorizon's last AEP (I believe I was in the top five in Florida) so I do believe I know a little bit about how the system works especially SecureHorizons.

I don't doubt that you know a little about how it works, but selling it and understanding it can easily be two separate things. They guy that sells BMW's might know a ton about the features and benefits, but easily not know much about how the car works and how to fix it. You're not the first agent to make a comment like this to me and I doubt you'll be the last, but just because you sold something does NOT mean you understand how the billing works. This isn't me taking a swing at you, it's just the way it is.

Congrats on the 170 enrollments this AEP, that's quite impressive!

 

[floridabroker]

I am just going to throw this out there.

This is a public forum.

Would our clients be thrilled with what some people write in attacks or mocking of others ability???

It is too bad this forum is not a truly professional one that we can all go to learn from without it turning into a "whose dick is bigger contest".

 

[Russ]

I am just going to throw this out there.

This is a public forum.

Would our clients be thrilled with what some people write in attacks or mocking of others ability???

It is too bad this forum is not a truly professional one that we can all go to learn from without it turning into a "whose dick is bigger contest".

I've been posting on here for almost a year and a half and it does get into a pissing contest way too often.

And before anyone jumps down my throat I'm not saying that applies to this thread.

 

[Josh]

I am just going to throw this out there.

It is too bad this forum is not a truly professional one that we can all go to learn from without it turning into a "whose dick is bigger contest".

I'm just going to through this out there.

Does your concern stem from fear of losing the contest?

Any relation to Ken Westphal?
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I've been posting on here for almost a year and a half and it does get into a pissing contest way too often.

And before anyone jumps down my throat I'm not saying that applies to this thread.

Good call on both points!

 

[HarryRenard]

Would our clients be thrilled with what some people write in attacks or mocking of others ability???

"whose dick is bigger contest".

Great to see you lead by example.

 

[sman]

How do you do it? I have a tough time keeping up with my book of business and it's nowhere near 4,000 strong. You've got to be pulling in $750k plus annually with that amount on the books.

I have been selling Medicare insurance since 1992 with over 1000 Med Supps and over 3000 MA under my belt.I did over 170 enrollments for SecureHorizon's last AEP (I believe I was in the top five in Florida)

 

[Bob_The_Insurance_Guy]

One thing I instruct my clients - not just Medicare (which includes Med Supps and Medicare Advantage), but Major Medical - is that they have a RIGHT as consumers to ask the doctor's office what will be performed, and how it will be billed.

I am taken up on this more times than not, and inevitably gets calls thanking me. If people know up front what is done and how much it will cost them, there is less frustration when the bill comes.

Just my two cents worth.