The official US government Medicare handbook.
By P J Klosinski
You have worked and have been forced to contribute to a Social Security System formed by the U.S. Government for which the federal government has no authority in the U.S. Constitution to create. An agency the same federal government has no authority to create is running a retirement and insurance plan directed at those receiving retirement benefits.
Crucial to this retirement plan is Medicare A and Medicare B inclusive with many preventive services to help prevent illness or detect health problems.
You are informed that you can decide how you want to get your coverage (see page 17 of your book). Original Medicare includes Part A (Hospital Insurance) and or Part B (Medical Insurance). If you want additional prescription drug coverage (Part D) it will be at an additional cost with requirements to join. Next you are told you can also add supplemental coverage again at an additional cost with conditions attached.
Medicare Part A
What is this? What does Part A cover? (see page 31-36) “Part A (Hospital Insurance) helps cover: Inpatient care in a hospital” as the primary claim.
A recent Part A in hospital stay discovered the “helps cover” determinations of Medicare do not cover Inpatient care as described in the coverage. Part A covered services are to include: ”blood, semi private rooms, meals, general nursing, and drugs as part of your inpatient treatment and other hospital services and supplies.” It also states: “You pay a deductible and no coinsurance for 1-60 days of each benefit period.”
“Am I an inpatient or outpatient? Staying overnight in a hospital doesn’t always mean you are an inpatient. You only become an inpatient when a doctor finally admits you as an inpatient, after a doctor orders it. You or a family member should always ask if you are an inpatient or an outpatient each day during your stay, since it affects what you pay and can affect whether you’ll qualify for Part A coverage in a skilled nursing facility.”
Patient determined only Medicare A was the choice suitable for them. Charges on Medicare B were similar to the self- pay charges under the former employer with a High Deductible healthcare plan due to massive increase in cost following the ACA implementation for small employers. Definitely not the fault of our employer as the business must be able to pay the cost of operation and if an employee benefit must be cut it was a benefit not a part of the financial arrangement although most employees did not understand, as Teamsters always claimed it was part of the pay structure. But Teamsters fund is now not able to pay the retirement and is also going bankrupt.
The Beginning of the Patient’s Journey into the Maze of Medicare Denial.
On July 16, 2017 patient went to the Johnson Memorial Health Hospital in Franklin Indiana one of the best 3 providers in the U.S. for Medicare compliance according to JMH hospital site for Medicare compliance https://www.johnsonmemorial.org/ . JMH website
On October 2, 2017 patient was noticed from Medicare that the total inpatient bill had been denied for claims processed July 11-October 2, 2017. Johnson Memorial Patient Biller Tracy Sipes immediately notified patient of the total Medicare denial and offered assistance through the hospital to pay the outstanding bill. Negotiations were made through JMH and the billing department and patient settled the hospital payment October 10, 2017.
Timeline of Events
Patient was admitted to the JMH Emergency Room exhibiting signs of severe edema, insomnia, low blood pressure, attending ER physician contacted Oncology Physician, described the symptoms after consultation Oncology Physician admitted patient to inpatient status. The number of services Medicare denied was 24.
The explanation for denial of the total bill was according to Medicare that: “P Our records show you did not have Part B coverage when you received this service. If you disagree, please contact us at the customer service number shown on this notice.” And Medicare further requested another submission of the bill under the following condition: “Q We have asked your provider to resubmit the claim with the missing or correct information.”
Patient never claimed to have Part B coverage. Patient explicitly declared there was only Part A coverage. The providers understood and filed the claim correctly with no claim for Part B coverage. Patient and Providers did not file with any information missing or incorrect
The notice ends with the instructions on “How to Handle Denied Claims or File an Appeal”
“Get More Details, If a claim was denied call or write the provider ask for an itemized statement for any claim.” Call 1-800-MEDICARE for more information. Medicare was called. Medicare stated open enrollment for Medicare B was not until December 31 with coverage to begin after 6 months in July 2018 way past the time for the Chemo treatments to be considered which began in July and are to be completed with no determination of results for 3-6 months thereafter.
How do I have this claim, because it is mine and I am freely posting the Medicare billing and the names of my providers to inform other Medicare A patients that the claims they file could also be denied in this manner. I asked JMH if these charges were covered the first day, Patient Accounts ran the bills and said there was nothing out of the ordinary and no reason for Medicare to deny any service. Now months later I receive this. My physicians, the hospital staff did their job, they tried to determine why I was in grave danger of dying. The ACA guidelines JMH and the Physicians must follow were followed as per their usual standards, yet the claim has been denied. It was determined in my case that I was not entitled to inpatient care until the disease is first determined by a Physician before going to the ER. Even though the beginning Medicare stated: ”Emergency department visit, problem with significant threat to life or function.” The disease which the government refuses to recognize as life threatening is known as Waldenstrom’s Macroglobulinemia.
I am contacting Representative Trey Hollingsworth with this issue as it is a federal denial of claim. Representative Trey Hollingsworth (RepresentativeTrey.Hollingsworth@mail.house.gov) In addition I have made a request to forward this article to the President for consideration on the executive order he can write to correct this situation for other recipients. And asking for a comment from both to be published here in Indiana. That is all for now. It has taken me quite some time to collect and compose. I hope this information causes others to ask and question all their interactions with their Physicians and Providers and to receive the same care JMH associates have given me in resolving this financial crisis issue.