Tricare For Life Claws Back $100,000 Claim

[somarco]

medicare isn't that prompt either

Medicare usually pays within 3 weeks of receiving the provider claim. Not speedy but quicker than many primary carriers.

Medigap pays in 2 - 4 business days after receipt of the claim from Medicare.

 

[annon123]

Medicare usually pays within 3 weeks of receiving the provider claim. Not speedy but quicker than many primary carriers.

Medigap pays in 2 - 4 business days after receipt of the claim from Medicare.

Then I guess with that client there are other issues. He refuses to have a medicare online account so he can't check and has to go by what the medical facility says and he gets in the mail. I guess the facility isn't very prompt.

 

[somarco]

. He refuses to have a medicare online account so he can't check and has to go by what the medical facility says and he gets in the mail. I guess the facility isn't very prompt.

A number of my clients never access their MyMedicare account even though I tell them how to set it up and access it.

When a client asks why their claim was not paid I ask about the information from MyMedicare . . . they can't say.

I tell them THEY need to send me the MSN (which may not come in until months later, or go to their MyMedicare account and get the claim summary or call Medicare and ASK for the claim summary to be sent to them.

If a claim is not paid by Medicare there is a code attached to the denial. If the procedure is not covered, and they have not signed an ABN form, they aren't responsible for paying it.

I constantly drill into them, to never pay a claim until AFTER Medicare has adjudicated it.

But yet, many times they pay the first claim that comes in from the provider.

A few years ago Rachel got an outpatient claim from the hospital for $20k. The provider coded the claim correctly but someone at the hospital keyed in a code that was off by one digit. This caused the claim to be adjudicated as NC vs approved.

The provider called the hospital, explained the coding discrepancy, and the claim was paid in full (remaining 20% covered by the Medigap).

On another situation, Rachel had OP consult in Dec 2024 followed by surgery in January. The first bill we got was in early March for $14,000. The bill was never submitted to Medicare, they were billing us as "self pay, no insurance". After they submitted it to Medicare we owed $87 (the Part B deductible).

I hate to think how many claims are paid by folks on PPO plans and the MA carrier had not (yet) seen the claim.