Fighting for insurance payment is a new thing for me, so I'm really not sure exactly what information it would be best to have going in.

I'm having to admit that I haven't been reading my Medicare Summary Notices/EOBs very well
I thought Medicare had paid the first time I had RT because I didn't get any notices or bills. The second time I had RT was September 2010. I've been billed by Scripps who says that Medicare didn't pay. Now Scripps tells me that Medicare also didn't pay for the first RT that I had in July 2009 and they/Scripps wrote it off. Scripps told me that I as a patient I can appeal the denial by Medicare. Scripps can't appeal because it is past the deadline that providers can appeal. That was the case for the first RT, too, they said.

I called Medicare. They are sending me the Medicare Summary Notice for the RT procedures done in Sept. 2010. I am to
1 - circle items for service in question (which will be just about everything - planning, simulation, treatment device, guidance for
placement and the RT itself)
2 - Write my whole Medicare # on the Summary Notice,
3 - Sign it
4 - Attach a letter explaining why I think it should be covered.

#4 is where I need to put together the collective brains from this Forum. Someone mentioned in a thread that they have worked with medical billing and others have appealed to their insurance companies. If I can get Medicare to cover this, it will help everybody since saying "Medicare covers it" tends to hold water with private insurance companies.

Total unpaid charges at Scripps are $1798.00

Help me build a case.

Flora

Flora,

I don't know how medicare works, I'm a pediatrician. But my husband worked for Blue Cross as a medical consultant for a while. The first accept or denie was done by a nurse with a cookbook style manual that they were not allowed to deviate from. The appeal was looked at by a physician but not in any particular spectialy. So you case might be reviewed by an ear nose and throat specialist.

The next level would be specialty specific buy if they give to a hand surgeon you would probably lose. In addition to all of the information you send ask specificly for it to be reviewed by a radiation oncologist. They may not honor your request but it can't hurt to ask.

Include the fact that Dr. S. from Germany presented this treatment protocol "BY INVETATION" to the American Society of Surgery of the Hand.

See ifyou can get cost of open surgery and compare it to radiation.

If anyone on this form has had medicre pay for this speak up and give specifics.

LubaM.:

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Flora,
Today I mailed you the copies of my Medicare forms from Nov. 09. I am under the impression that Medicare did pay
(see page 2 of 4, middle of page). Let me know when you get the forms...



Luba

Edited 02/26/11 03:21

Luba and Flora,

Compare your CPT procedure codes and see if there are any differences. They would not be on the EOB, it would have to be an itemized bill from Scripps. If you call Scripps they will have the informaton in billing and should provide it to you. One minor difference could be the reason one was paid and one was't. Also compare your diagnosis.

Without a release of information signed by both of you, no one at Scripps or Medicare will talk to you about the others claims, diagnosis, procedure codes or payment details. You can limit the release to just certain dates, procedures, and for a limited time frame. With that release of information they should be able to compare the paperwork, otherwise you might not ever be able to know why they paid Luba's and not yours Flora.

Hope this might help??


Lori

lauriw:

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Hi, I am appealing my denial for RT by BCBS. The billing lady told me that Medicare does not pay for RT, which would have been good for my case. That's all I know about Medicare. Maybe they used to.
LauriW