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  #1  
Old 09-09-2011, 03:32 PM
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apple19 apple19 is offline
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Medicare Deductible Overpayment

Hi all,
I have a question about medicare deductible. I hope this is the right place to post this question.
Last week I rec'd a call from my doctor's office saying that I still owe the remaining balance towards my Medicare deductible. Every year my doctor ask for the deductible up front. Many of us do not have it so he allows us to pay in increments. Well I still owe a balance and he made sure that was first thing on the list when the nurse called me about my blood work results. I called Medicare to find out if there were others ways to pay the money(maybe on website or telephone payments, etc.) or did I have to pay at the doctor's office. Medicare rep. told me I NEVER have to pay the deductible up front. As the doctor submit a claim, a portion of the payment goes towards my deductible. I am actually over paying when I pay all at once in the beginning of the year. He has been doing this for years. Can someone clarify about the Medicare deductible for me so I can talk it out with him? If I do not get any results from him, Medicare rep. said I can file a fraud claim against him.

Thank you.
Take good care!
  #2  
Old 09-09-2011, 04:10 PM
0485c10 0485c10 is offline
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idk...its confusing what medicare pays and doesn't. by law a doc or health care provider is not allowed to charge more than the amount medicare allows to be charged... my deductible is always paid by my medicare supplimental plan, so the doc collects no money from me....but he recieves the full amount medicare allows him to charge. even if medicare doesn't pay the deductible or the last 20%, my medicare supplimental plan does. if i didn't have a medicare supplimental plan i would have to pay the deductible and copay at the appointment.

its not fraud if he hasn't collected more than he billed and he billed what medicare allows for the service.
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Old 09-09-2011, 04:29 PM
0485c10 0485c10 is offline
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you should get a monthly statement from medicare stating what was charged, what medicare allows, what medicare pays an what you can be billed.

if you have medicare supplimental insurance paying the part you can be billed the doc should collect no money from you, but if you don't have supplimental insurance that pays the deductible you are responsible for it...

its fraud if you have a supplimental policy that pays the deductible & the doc is collecting a cash deductible from you also. you should receive quarterly statements from your supplimental insurance to see what they paid.

if you combine your medicare statements with your medicare supplimental insurance statements you will be able to determine if he has committed medicare fraud and should be reported.
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Old 09-09-2011, 07:57 PM
gomer gomer is offline
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As I understand it, NORMAL procedure, the doc bills medicare first, then IF you have supplemental ins they PAY the deductible...

I ran into a weird non-typical situation as far as my MS care. I had BCBS supplemental ins till I was dropped retroactive earlier this year. (retro active back to a few days before a bone tumor was found.......) I was told I would have to REAPPLY, but I chose to gamble and didn't. I think I may try Humana this next year.

The realy weird situation I ran into was this. I get my MS care thru the VA, but have not YET been able to get cooperation getting it service connected (long story).

Every VA visit I have to show my medical ins card/s. What the VA was doing (when my BCBS was in force) was to bill BCBS AND bill me co-pays. They did not consider the BCBS payments as all or even part of my VA co-pays. So for me, as far as MS care goes, I was paying for medicare supplemental coverage and still having to pay co--pays. I went to the patient advocate with no luck about it, nor a good answer either.

When I had BCBS coverage, they did pay 100% of the deductible for my doctor visits, tests & power chair etc.

Gomer
  #5  
Old 09-09-2011, 09:24 PM
Redwings Redwings is offline
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Quote:
Originally Posted by apple19 View Post
I called Medicare to find out if there were others ways to pay the money(maybe on website or telephone payments, etc.) or did I have to pay at the doctor's office. Medicare rep. told me I NEVER have to pay the deductible up front. As the doctor submit a claim, a portion of the payment goes towards my deductible. I am actually over paying when I pay all at once in the beginning of the year. He has been doing this for years. Can someone clarify about the Medicare deductible for me so I can talk it out with him?
Hi apple19:
You may want to call Medicare again and talk to another representative, because what the first one told you doesn't make sense.

First, what the rep told you directly contradicts the information given in the Medicare beneficiary handbook, which says:
"Under Original Medicare, if the Part B deductible applies [B]you must pay all costs until you meet the yearly Part B
deductible [I]before[/I] Medicare begins to pay its share[/B]. Then, [B]after your deductible is met[/B], you typically pay 20% of the Medicare-approved amount of the service."

This policy says you must ALWAYS pay the deductible up front, not that you [I]never[/I] pay the deductible first. If you can't locate the copy of the handbook Medicare sent you last year, you can access it online to see for yourself what the policy book says.

Many years ago, when I was doing medical billing, it was the Medicare policy (and, therefore, doctors' policy) for patients to pay the deductible up front. The current Medicare instruction book says that that policy has not changed.

Now, that's the policy for original, straight Medicare. If you have a supplemental policy that's supposed to have picked up your deductible, that's a separate issue. The Medicare representative should have referred you to the carrier of your secondary policy to get it straightened out. However, your post doesn't say anything about you having a supplemental policy.

The fact that your doctor has allowed you to pay your deductible over time (if that's what he's doing) is very generous. Generous to the point that it actually violates the Medicare policy that you must pay it all up front. Back in the late 1980s and early 1990s, some doctors were so generous that they were waiving the 20% copay. That was a clear violation of Medicare policies. When Medicare found out about the scope of the violation, they put an end to it by financially penalizing doctors for waiving fees.

The second thing that the representative told you that makes no sense is that the deductible comes out of claims. It does not. The deductible is an out-of-pocket cost to beneficiaries. That means that YOU pay it. A claim involves the doctor's Medicare-allowable fee, the portion that YOU pay out of pocket and the payment that Medicare makes to the doctor.

To say that "As the doctor submits a claim, a portion of the payment goes towards my deductible" can't be true. What portion of [I]what[/I] payment? You pay your required 20% copay to the doctor and Medicare pays its part of the fee to the doctor. The doctor doesn't pay anybody for the act of providing services. (He only "pays" in that reimbursements are barely adequate to cover expenses.) And if you don't pay YOUR deductible and Medicare surely doesn't pay YOUR deductible and the doctor doesn't pay YOUR deductible, where in the claim is your deductible paid? It ISN'T. The deductible is paid BY YOU up front at the beginning of the year, and the claims filed [I]then[/I] apply your payments to the deductible, not after.

Medicare policy doesn't allow for payment of a 20% copay and then a small portion of deductible. And even, for sake of argument, it did, how would anyone know how much portion of a deductible to charge to be sure that the deductible is fully met by the end of the year? And wouldn't the deductible stop accruing once the amount was met so Medicare couldn't allow you to overpay?

It isn't clear from your description what happened with your Medicare payments. It doesn't seem possible that you could still owe deductible payments in SEPTEMBER, because Medicare requires that the deductible be met [I]up front[/I] at the beginning of the year. Regardless, what the Medicare representative told you is of no help because s/he was off-base by contradicting the information in the Medicare handbook.

Having done Medicare billing myself, I can't think of any way for you to have "overpaid" your deductible. If you have straight Medicare, you pay a deductible at the beginning of the year -- which is credited to your account that way by Medicare -- and then 20% copays. I don't know how it would work that the doctor could file a claim with partial deductible payments by you, and 20% copays going into effect before the deductible was met, since the Medicare policy is to consider all out-of-pocket payments by you to [I]first[/I] be applied to your deductible, then toward the 20% copays. But once Medicare has evidence that your out-of-pocket payments equal the deductible amount, your deductible has been met and no further payments are applied to it. The Medicare billing system doesn't allow for overpayment of a deductible.

Your monthly EOBs going back to the first of the year should explain how your deductible was met, when it was met, and when your 20% copays went into effect. If you have a supplemental policy, their documents should explain the same things. If you have evidence from your own payment records that your doctor has been charging you MORE than a 20% copay, calling that extra amount a "deductible" and not reporting it to Medicare, THAT would be fraud. But you have a lot of research and financial unraveling of your own to do before you have evidence to accuse your doctor of that.

AND you should speak with a different Medicare representative to find out why the Medicare beneficiary instruction book says one thing about the annual deductible and a Medicare rep told you the opposite over the phone.
  #6  
Old 09-10-2011, 04:47 AM
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Thank you all so much for clarification. I do have BCBS Federal Employee Plan along with Medicare. All my doctors' visits, tests, labwork, MRI's , etc are all covered and I don't have any additional out-of-pocket expenses. I will pull out my Medicare booklet, BCBS booklet, give a call back to Medicare as well as BCBS. And now when I get my statements in the mail I will understand them much better. Thanks for the vital information.
  #7  
Old 09-10-2011, 08:37 AM
lemstar lemstar is offline
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Clarification!

I do medical billing. Here is the deal:
**Doctors are not supposed to collect any money up front from Medicare patients. They are to wait until Medicare processes the claims.
**Paying the deductible up front doesn't mean you have overpaid, just that you paid early.
**Supplemental insurance, secondary to Medicare, SOMETIMES covers the Medicare deductible, and sometimes doesn't. It depends on your specific plan.

So, while it is likely not entirely legal to ask you to pay the deductible up front, in the end, it really doesn't matter, as you will be paying that Medicare deductible to someone, if you get any medical coverage from Medicare, unless your supplemental covers it, in which case, you pay nothing.

What they meant by the deductible comes out of the claims directly is this: when I file a Medicare claim in the beginning of a year, when I get payment from Medicare, they first take out the deductible, before paying providers. For example, if I bill $250, all of which is covered, Medicare will take out the $150 (or so) for the deductible, which means the deductible has been met, and then pay 80% of what is left.

Doctors sometimes try to collect the deductible up front because it usually takes 6 weeks for Medicare to process a claim, and then it get sent to the supplemental insurance, who take another couple of weeks, so it can be a long time before docs can collect the deductible, by which time the patient may be hard to contact, and hard to collect from.
There....any questions? LOL....
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Old 09-10-2011, 01:06 PM
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apple19 apple19 is offline
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Wow lemstar Thank you. That is even more clearer. I will pay the rest of my deductible. That is what I was originally going to do when I called Medicare. I just called them to ask if I had to pay it to the doctor or was there some other way to pay. The Medicare rep. started telling me all that was told. But I am so glad I ask this question here. You all are awesome. Thanks again.
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Old 09-10-2011, 09:14 PM
Redwings Redwings is offline
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Ah, so it sounds like the current Medicare policy is to take beneficiaries' deductibles out of the [I]doctors'[/I] pockets at the beginning of the year and make [I]them[/I] scramble to somehow collect the money later. (It didn't used to be that way. Offices were required by Medicare to collect deductibles up front, just like the current guidebook still says.) Well, it's a cinch to understand why so many doctors are dropping out as providers in Medicare!

apple19, since it sounds like Medicare sort of stole the deductible from your doctor, leaving him to collect it from you during the year, you very well could still owe him for the rest of the deductible. In that case, it [I]has[/I] been very generous of him to let you pay it a bit at a time over the year. What still isn't clear is why your [I]supplemental[/I] policy didn't take care of this and pay your doctor back earlier in the year...
  #10  
Old 09-11-2011, 09:55 AM
onlyairfare onlyairfare is online now
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Because of low payments, there are places where Medicare patients have trouble finding a doctor to take care of them because the doctors have either quit taking new Medicare patients, or the doctors have decided not to participate in Medicare at all.

I used to live in western Washington State, where Medicare payments to doctors did not even cover expenses; in short, the primary care doctors donated 3% to Medicare every time they saw a Medicare patient. Therefore, almost every primary care doctor in the county quit taking new Medicare patients (and this in a city that frequently appears in the Top Ten lists of retirement communities), and a few even dismissed long-standing patients when they went on Medicare. They just couldn't afford to see Medicare patients at a loss.

The local hospital opened a Senior Clinic and employed primary care physicians to see Medicare patients. They could do that profitably because the hospital was paid twice as much as a private practice doctor to see the same patient for the same problem. Most specialists there still see Medicare patients because specialists are paid more than primary care.

That Senior Clinic is only for Medicare patients over 65 - those under 65 and on Medicare because of disability are pretty much out of luck. They have to go to the county clinic for indigent people, unless they are wealthy enough to pay cash for all primary care services (ha - most disabled people are not wealthy).

Apple19, sounds like you are lucky that you have the Blue Cross in addition to Medicare, and you also have an understanding doctor who lets you make monthly payments on your deductible.
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Old 09-11-2011, 10:46 AM
0485c10 0485c10 is offline
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Man this thread gets more & more complicated with better and better replies. i think without knowing your specific coverage situation, but federal employees BCBS sounds like a good one, its tough to answer.

i think you need to go through your policy and billing statements--it seems to me at one point when i was signing up for my supplimental medicare insurance i had to check a box whether i wanted the payment to go directly to the doc or i wanted it to go to me. i checked directly to the doc...if you didn't your supplemental plan may be waiting for YOU to submit claims so they can the reimburse YOU for what you have paid...or like lemtra said, perhaps your BCBS policy doesn't cover the deductible?

just one more possibility to check among many possibilities.
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