Senior Client Had Plastic Surgery

[eagles12]

I received an email from a client who has a Plan-F MedSupp with me.
She said her Dr had advised her to have her eyelids reduced as this was blocking her visibility. She received a referral to a Palm Springs plastic surgeon
who subsequently performed the procedure.

The client wants to know how she can file the claim. I was never informed
of her intention to get the surgery. I gave her the Tel # of the MedSupp company and instructed her to ask for customer service. I asked that she call me later if she had any questions once she talked to customer service. She wants to be reimbursed $2500 for the surgery plus $95 for the optometrist.

My concern is that she may not be covered. How should I have handled this?
Thanks.

 

[rugerred]

I received an email from a client who has a Plan-F MedSupp with me.
She said her Dr had advised her to have her eyelids reduced as this was blocking her visibility. She received a referral to a Palm Springs plastic surgeon
who subsequently performed the procedure.

The client wants to know how she can file the claim. I was never informed
of her intention to get the surgery. I gave her the Tel # of the MedSupp company and instructed her to ask for customer service. I asked that she call me later if she had any questions once she talked to customer service. She wants to be reimbursed $2500 for the surgery plus $95 for the optometrist.

My concern is that she may not be covered. How should I have handled this?
Thanks.

My guess Medicare denied the bill and that is why the supplement isnt paying.

 

[LostDollar]

Medicare is who/the one that will determine whether the procedure is covered or not, and the medicare amount.

The medsupp company will pay nothing if Medicare does not cover the procedure.

Her starting point should have been two questions for the Palm Springs surgeon.

1) Do you accept original Medicare (or do you accept original medicare assignment)? I am still unclear as to which is the most precisely correct question.

2) Is this a medically necessary procedure which Medicare will cover or a cosmetic procedure which they wont?

I don't have enough experience with Medicare yet to know if a Medicare beneficiary can file a claim directly with Medicare if the medical provider did not file the claim.

As a patient, my starting point would have been further back, with my family doctor. I'd have asked the family doctor for referral to a surgeon who accepted medicare and agreed with the family doctor's position that it was a medically necessary procedure.

 

[rugerred]

Medicare is who/the one that will determine whether the procedure is covered or not, and the medicare amount.

The medsupp company will pay nothing if Medicare does not cover the procedure.

Her starting point should have been two questions for the Palm Springs surgeon.

1) Do you accept original Medicare (or do you accept original medicare assignment)? I am still unclear as to which is the most precisely correct question.

2) Is this a medically necessary procedure which Medicare will cover or a cosmetic procedure which they wont?

I don't have enough experience with Medicare yet to know if a Medicare beneficiary can file a claim directly with Medicare if the medical provider did not file the claim.

I thought that's what I said.

 

[goillini52]

I received an email from a client who has a Plan-F MedSupp with me.
She said her Dr had advised her to have her eyelids reduced as this was blocking her visibility. She received a referral to a Palm Springs plastic surgeon
who subsequently performed the procedure.

The client wants to know how she can file the claim. I was never informed
of her intention to get the surgery. I gave her the Tel # of the MedSupp company and instructed her to ask for customer service. I asked that she call me later if she had any questions once she talked to customer service. She wants to be reimbursed $2500 for the surgery plus $95 for the optometrist.

My concern is that she may not be covered. How should I have handled this?
Thanks.

The claim needs to be filed with Medicare. Medicare decides if it'll be covered. If Medicare approves the charge, her Plan F will pay the balance. The fact that the plastic surgeon had her pay up front leads me to believe that he doesn't think Medicare will cover it.

As her agent, you should call the company...not instruct the client to do it. If you do it for your clients, you'll learn the answers to basic questions like this. If your client has to call the company for you...what do they need you for?

 

[somarco]

Eyelid surgery can be covered if the droop is pronounced enough that vision is impaired. Ophthalmologists know the criteria and how to accurately measure the droop.

Optometrists do not.

Can't say if plastic surgeons know the parameters for getting the procedure covered or not.

Red is correct. If Medicare denied the claim there is nothing for the gap carrier to pay.

Sounds to me like she wanted cosmetic surgery, which is not covered, and thought she found a loophole by asking an optometrist for a referral without providing a justifiable diagnosis.

 

[LostDollar]

I thought that's what I said.

My answers take me quite a long time to think out and type out. There were no answers in the thread when I started.

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Eyelid surgery can be covered if the droop is pronounced enough that vision is impaired.

And there's an "exciting" lunchtime ride, when you are tearing down the road with a guy holding his eyelids up with one hand and steering with the other. There was a technical name for his condition but I don't remember it.

 

[ICACharleston]

I just had this surgery last week. My doc had to submit photos and peripheral vision test results to get it pre-approved. That is how you prove it is not cosmetic but functional surgery. It's a little late in your client's case, so she may be stuck.
The procedure is called blepheroplasty, Medicare will pay for upper eyelids, not lower and not cosmetic.
Without Medicare discounts, I think the doc billed around $7500, the facility about the same and the anesthesiologist about $700. I think your client is going to be stuck unless she or the doc can submit evidence that this was not for cosmetic purposes. Let us know how it plays out.

 

[LostDollar]

I just had this surgery last week. My doc had to submit photos and peripheral vision test results to get it pre-approved. That is how you prove it is not cosmetic but functional surgery. It's a little late in your client's case, so she may be stuck.
The procedure is called blepheroplasty, Medicare will pay for upper eyelids, not lower and not cosmetic.
Without Medicare discounts, I think the doc billed around $7500, the facility about the same and the anesthesiologist about $700. I think your client is going to be stuck unless she or the doc can submit evidence that this was not for cosmetic purposes. Let us know how it plays out.

Would your numbers and her $2500 match up? 20% 15K=3K.

Maybe the Surgeon made her pay the 20% portion.

(And just because of my experiences with H many years back-just curious-how is the surgery affecting your quality of life so far?)

 

[ICACharleston]

Would your numbers and her $2500 match up? 20% 15K=3K.

Maybe the Surgeon made her pay the 20% portion.

(And just because of my experiences with H many years back-just curious-how is the surgery affecting your quality of life so far?)

No, the Medicare allowed amounts were MUCH lower. I'm in South Carolina, his client is in California, and we don' t know what she had done. If Medicare was paying the 80% , the MedSup would have paid the rest. My cost was supposed to be $295 but I think I was overcharged and have filed a grievance.

I felt an initial improvement in vision but can't swear to it without going through the testing again.