Monday, 11:50 PM
High-Level Journal Summary: Looking more closely at a question posed in my 10/3/07 online journal entry about costs that may not be paid by Medicare OR by my current secondary insurance...the insurance that used to be my primary insurance until Medicare kicked in on 9/1/07.
What issue caused me to look more closely? I had blood work done on 10/1/07 for my Medicare physical exam, and this blood work may not be paid for either Medicare OR my secondary insurance. I do not know the answer at this point -- it is yet to come.
In the meantime, I had to sign a document (shared in full) which says I must pay any and all costs for these tests, no matter what Medicare pays or what my secondary insurance pays. All this drives home the point that I need to make very good personal health insurance choices before my COBRA expires on 11/23/07. Otherwise, costs could spiral in fiscally dangerous directions.
Countdowns:
1.) Day 8 of 28 in my 26th 5/23 Temodar chemotherapy cycle. I am still trying to break out of the fatigue from my last round of chemo. I feel like I am close, but I am not there yet. The strong physical impact of last week still lingers.
2.) On 10/10/07, re-do my 7/31/07 Speech-Language Pathology Testing at NIH.
2007 Seizure Activity:
1.) Last Simple Partial Seizure, or SPS, was 3 days ago.
2.) In 2007, I have had 68 SPS's in 281 days. This is an average of 1 SPS every 4.1 days.
Website Updates:
All sorts of small changes are being implemented by Blue Water Media this week. There are far too many to list. However, there is one feature that is especially useful. When a reader clicks on the calendar in the Daily Journals tab, they can move forward/backward to the next/previous journal entry simply by using the right arrow ( --> ) or left arrow ( <-- ) on their keyboard. How cool is that?! Very useful for navigating from journal to journal.
Actual Journal: In my 10/3/07 online journal entry, a reader named Trish -- who is a brain tumor survivor who specializes in Medicare and Personal Health Insurance -- asked some insightful questions. A few of her questions were particularly timely, simply because they became potential issues for me when I got my Medicare physical exam on 10/1/07.
Reminder of Trish's questions
Here are excerpts from Trish's questions that get to the heart of matters:
The biggest problem I see in dealing with Medicare patients on a daily basis is the lack of what their secondary coverage picks up. Medicare is what it is, and there is not much you can tweak with that, it's pretty cut and dry. But the secondary coverage is what is really going to save your pocket book. A few good questions regarding the secondary coverage:
• If Medicare's allowable amount is less than the secondary plans allowable amount will secondary pay at all?
• Medicare will not cover anything they consider "routine" for the most part. Does your secondary plan cover routine services?
Imagine my surprise on 10/1/07
I went to my internist, Dr. Les Gavora, on 10/1/07. I needed to get a complete physical exam since Medicare needs this report to help ensure my qualification for Medicare coverage.
I have been to Dr. Gavora's office many times over the past few years. Since I had a Medicare card this time, along with my secondary coverage that is good until 11/23/07, I told his office about this change in coverage. They made a photocopy of my new Medicare card. And that's when new papers started to be pulled out of drawers and processes began to change.
Advance Beneficiary Notice (ABN)
It appears that the meeting with Dr. Gavora is going to be covered by either Medicare or my secondary coverage. There were no apparent issues with that. However, when I went to get various blood work tests upstairs at Quest Diagnostics Incorporated, papers were prepared about what costs might not be covered. Here is what was presented to me, verbatim:
NOTE: You need to make a choice about receiving these laboratory tests.
We expect that Medicare will not pay for the laboratory test(s) that are described below. Medicare does not pay for all of your health insurance costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, Medicare probably will not pay for the laboratory test(s) indicated below for the following reasons:
• Medicare does not pay for these tests for your condition: 3 tests listed
• Medicare does not pay for these tests as often as this (denied as too frequent): 1 test listed
• Medicare does not pay for experimental or research use tests: 0 tests listed
The purpose of this form is to help you make an informed choice about whether or not you want to receive these laboratory tests, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.
• Ask us to explain, if you don't understand why Medicare probably won't pay,
• Ask us how much these laboratory tests will cost you (Estimated Cost: $377.05), in case you have to pay for them yourself or through other insurance.
PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.
_X_ Option 1. YES. I want to receive these laboratory tests.
I understand that Medicare will not decide whether to pay unless I receive these laboratory tests. Please submit my claim to Medicare. I understand that you may bill me for laboratory tests and that I may have to pay the bill while Medicare is making its decision. If Medicare does pay, you will refund to me any payments I made to you that are due to me. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare's decision.
___ Option 2. NO. I have decided not to receive these laboratory tests.
I will not receive these laboratory tests. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won't pay. I will notify my doctor who ordered these laboratory tests that I did not receive them.
10/01/2007
Date
_______________________________________________
Signature of patient or person acting on patient's behalf
NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to Medicare, your health information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare.
OMB Approval No. 0938-0566
Form No. CMS-R-131-L
The potential cost
When I go to Quest to get my blood checks every two weeks, the costs are very high, but my insurance helps defray these costs significantly. By the time the final bill lands in my USPS mail box, it is a matter of a few dollars with each blood check.
But when I signed the ABN on 10/1/07, I was looking at a cost of $377.05. That is just a bit more than the $2.97 invoice I otherwise get for each of my bi-weekly blood tests. And last time I got my yearly medical exam by Dr. Gavora, all these tests were done and covered without issue. The only things needed were the prescriptions from Dr. Gavora.
In any case, I went ahead and said that I would pay any and all costs. I needed all these tests, even though I had no idea what would be covered by Medicare and what would be covered (or not) by my secondary coverage. (NOTE: My secondary coverage used to be my primary insurance coverage until Medicare kicked in on 9/1/07.)
Bottom line
While I can afford the above costs without issue, it does make me start to do the math on how costs can quickly add up IF the appropriate secondary insurance is not in place. Trish is right. Great questions need to be asked to ensure that I have proper coverage in place when my COBRA coverage ends on 11/23/07. Otherwise, costs could quickly spiral in the wrong direction.
