I just got an ABN from the blood test lab, and I am very confused.

[Susan Calvin]

It was a form that said they didn't expect Medicare to pay for some or all of the tests, and they wanted me to sign it saying I'd pay if Medicare didn't.

I don't know if it was all or some at this point actually, because they wouldn't give me a copy of it and I said well I'm not going to pay for it if I can help it so I'm gonna check into this.

Checking into it did not go well.

I called the doctor's office and they basically said they couldn't help me understand what was going on. At all.

Then I called Medicare. They said they couldn't help either. Even though I gave them the names of the tests and the codes. Which I really found nuts, because when they get bills, I'm quite sure they figure out whether they will pay for them or not.

[TreasonousBastard]

1. That unquestionably sucks, but you are stuck with a Hobson's choice...

Agree and you run the chance of being charged or tell them to stick it and not getting any benefit from the tests.

The simple truth is that it is accepted that the patient is almost always stuck with the difference and the form may be simply an acknowledgment of this to reduce the screaming and complaining.

[BittyJenkins]

2. I just went through the same thing

My orthopedic doctor wanted me to have my vitamin D checked out because I broke my shoulder and it was not healing well. When I went for the test I was told medicare would not cover it. That one lab would have cost close to $300 out of my pocket. It all got down to the code. The lab called the office and asked them to change the code number to something that medicare would cover and they did. It is my first year on Medicare so I am learning too. All and all it has been great but you have to be aware.

[yellowdogintexas]

6. sounds like the doctor's office may have used an incorrect diagnosis or code on the written order

However the lab did the right thing to advise your physician that the order as written would not support that particular thing and to send a corrected order. That is good service on the part of the lab Maybe a Vitamin D panel is only covered for certain diagnoses or the wrong lab code was used. A simple transposition of digits in the code can mess things up too.
Next time you are at the doctor's ask the insurance person to show you the coding book. It's huge, and there are a lot of things which are "the same thing only different" especially in lab and xray because there are so many of them.

Glad you were able to get that worked out.

There are very few things Medicare will outright deny.

[Susan Calvin]

11. Pretty sure it comes down to the code in my case.

But the lab I went to did not communicate with the doctor's office, even though they're in the same building. They just told me sign it or don't, and check out what the heck is going on yourself.

[dixiegrrrrl]

22. Did you get the test????

You have a legal right to have a copy of all your lab tests, you have a legal right to get copies of anything they want you to sign.
The lab cannot do a test without doctor orders, so they must be in communication with your doc.

Your doc should be able to tell you what tests are covered by insurance or Medicare.

Unfortunately, there are several important questions any insured person needs to ask before any non-emergency procedure.

Is this covered by Medicare is the first and most important one.
Followed by asking name of test, what it tests, when the results will be in. Don't be afraid to write things down, to ask for spelling if you need that. In fact writing things down tells your medical staff that you are serious about having information.

I would report any rude interactions to the head of the lab....and to your doc.

Remember, YOU are the employer, they work to get your money.

[Susan Calvin]

23. Thank you for asking.

There's nothing urgent about them, I really only went in for the thyroid, which is been exactly the same for over two decades. I know what the rest are for, and I'm basically taking them to indulge my doctor. If I do take them, depending on who pays.

That's interesting that I'm entitled to a copy of anything they want me to sign, because when I asked for a copy of the ABN they wouldn't give it to me. All they did was give me back my orders with a notation that I refused due to ABN.

I'm going to go back and figure it out more during Christmas break. I didn't have time during the incident I posted about, because I was just going on my way to something else, not expecting any problems.

Absolutely nobody was informative the first time around. The nobody includes my doctor's office and Medicare. Possibly the lab might have been informative if I had had time while I was physically there. Although the only thing they did recommend to me was calling Medicare, which I did, and got nowhere as far as getting any information.

What annoys me is that they didn't say Medicare won't pay they said if Medicare doesn't pay. Oh, I said, how do I know if Medicare will or won't and that's when the fun started.

[CharleyDog]

3. Medicare pays for 80% of what is deemed "reasonable"

Thus if the lab bills $300 to Medicare, and Medicare says "that is not reasonable, we will only pay 80% of $200." Then the lab bills you for the extra $100 and Medicare bills you for 20% of $200.

[pnwmom]

4. Except Medicare providers are required to accept the amount Medicare says is reasonable -

80% of the reasonable amount from Medicare and 20% from you (or your additional insurer.)

Medicare providers aren't supposed to be billing anyone for the amount beyond the reasonable cost.

[yellowdogintexas]

5. not exactly how payment is determined

I used to process claims for Medicare Part B and after that for other types of medical insurance.Providers who accept Medicare's allowable charge as full payment know that was what they will receive. If you see a physician who does not participate in Medicare you can be billed the full amount, and any coverage by insurance will be sent directly to the patient.)

Medicare or any other insurance does not bill anything back to the patient, but the provider does. Even if the doctor's office bills you, if the insurance person knows it's wrong they are contesting it and if htey get an adjustment you will get a refund from the doctor. You get an explanation of benefits from Medicare which shows how the claim is broken down but that is not a bill in fact it clearly states that.

For a contracted provider, if bill is $300 with an allowable charge of $200, the provider receives 80% of $200. The provider may then bill the patient 20% of $200 and that other $100 is written off. The providers know their allowable charges they are part of their contract. This is how labs generally work with insurances in general. If the particular service is not in the provider's contracted services then it would be denied and the provider can bill for the whole amount. If the provider is not a participating provider then they can bill you for more than 20% of the adjusted amount. But you won't get a bill from the insurance company for the amount they didn't cover.

The physician ordering the labs should know which of the big labs are participating providers and that is where one should go. First rule of medical insurance: never go to a non participating provider.
The error could have been made by the doctor in the written order, the lab in submitting the claim or the claims processing at the Medicare office. Somewhere along the way it can be corrected. If a lab charge is denied, go to the doctor who ordered it to start the review. You have to let them know because they are not going to see the payment info from the lab

I suspect that doctor's office called to double check the code and ask for the claim to be refiled with a correction if it was coded in error. If the doctor's office put an incorrect diagnosis or code on the lab order that is sent over, then the doctor's office will make the correction, resend the order and the lab will refile. The lab wants to be paid too. Normally when a claim is rejected by insurance, the provider gets right on it .

[Susan Calvin]

12. The lab I went to did not even contact the doctor's office.

Even though they are in the same building. Just told me to look into it myself. Which has not been productive. Even though that lab is very convenient, I don't think I'm going there anymore.

[yellowdogintexas]

7. Susan it may have been some or all of the charges.

Most providers will have a similar form to confirm you will pay the difference after insurance.
It's pretty normal in medical insurance and your doctor's insurance person would know that. Ask the dr's office if they have a similar form that patients sign stating that he/she will pay for any non covered service or the portion not paid by insurance. I know I sign one every year at my doctor's office.

Medicare.gov isn't going to know squat about how that payment will pan out or what labs may end up being denied in full. They are responsible for elegibility, premiums and so forth, but they don't do the claims and won't be trained in those specifics.

If you have an Advantage plan the company you bought it from could help you find out if any of the labs were totally non covered. If you have Part B Traditional, there is customer service information on your explanation of benefits forms and they can help you. Your Medicare manual that we all get probably has the phone number you need.

Good luck!

[Susan Calvin]

13. I'm on traditional Medicare and TRICARE.

I looked into supplement plans when I became eligible and everybody told me Medicare and TRICARE you don't need anything else you are crazy for even asking. Amazing that I ran into so many honest people.

I have been on Medicare since 2017, and this is the first issue I've run into. I think it's the doctor's office not coding it right, and then the lab not even being willing to call the doctors office.

An additional complication is that I had to change doctors or follow my previous doctor a long way away. I bet she would not have let this happen.

[abqtommy]

8. Medicare isn't shy about stating that if a provider won't cover the cost of a procedure then the

patient DOESN'T HAVE TO PAY. I went to a neurologist for alzheimers/dementia screening and an
EEG/electroencephalogram. Medicare refused to pay on the bill due to the competence of the clinic being unknown to them. (I called Medicare to find that out.) I relayed that information to the clinic then refused to pay the bills they sent me. Finally the clinic found some state agency to help pay and I did
pay the small balance left. I still don't know if the clinic cleared things up with Medicare but this wasn't my first EEG and I told Medicare that in my opinion they were very competent. Be willing to stand up for yourself.

[Susan Calvin]

16. Wow, it sounds like you talked to some people at Medicare who are actually competent.

The one I talked to so far sure wasn't.

[still_one]

9. From my experience that is standard, if Medicare or any insurance for that matter doesn't cover

something, they want you to acknowledge that you will be responsible for the payment.

Whether Medicare covers it or not depends on the type of Supplemental Coverage you have or Advantage Plan

[Susan Calvin]

14. I'm not sure now, since they wouldn't give me a copy of the ABN,

but I think they rejected only three or four tests out of the five or six. I'm convinced it's a coding issue, but my (new) doctor's office doesn't seem to realize that's their responsibility. If they really think I should have the tests.

[still_one]

15. I think your assessment is probably right. Regardless, if you need the results in orders to know

how to proceed, Because of the holiday weekend you most likely won’t be able to get it straightened out with your doctor until next week

All the best to you

Take care

[Susan Calvin]

10. Thank you so much for the responses.

I don't have a deductible issue because I am on Medicare primary and TRICARE, military, secondary. My Medicare premium is basically all I pay.

Yes, I would expect the doctor's office to know if Medicare would allow it or not. But if I haven't said already I called them and they said we are not in the business of telling you if Medicare will pay it.

[PoindexterOglethorpe]

17. That is absolutely standard.

Medicare only pays for certain tests, or only pays for x number of a particular test in a given time frame. If you don't sign you won't be able to get the blood test. And it's almost impossible to find out ahead of time what it will cost you if Medicare doesn't pay.

But Medicare should pay for just about everything that's routine.

I used to to outpatient registration at the local hospital, and this form was always used with the Medicare patients.

[Susan Calvin]

18. Actually, they had the cost right on the form they wanted me to sign.

What I can't find out is what Medicare would or wouldn't pay for.

I'm currently working on the assumption that the ones listed they don't think Medicare is going to pay for, because as I recall it wasn't all of them. But maybe it was.

There's nothing for it I guess but to go back to the lab and try to get them to explain the coding to me. I didn't have time the first time, because I just dropped by on my way to somewhere else, and I didn't expect anything out of what's previously been ordinary to happen.

I haven't had any blood work whatsoever in two years, and this is standard stuff they check, so I'm gonna think it's really weird if Medicare won't pay for it.

[PoindexterOglethorpe]

19. Oh, good, I'm glad they had the cost.

At least if you do get charged, you'll already know what it is.

And again, that form is simply standard. I had more than one patient tell me they found the signing to be useless, since their tests were always covered. There is probably someplace, possibly on the Medicare website, where you can find out what frequency of what tests is covered.

[Susan Calvin]

20. You're probably right about the Medicare website, but I have had no luck so far .

I still can't believe my doctor's office didn't know what was covered and at what frequency, or at least wouldn't say so .

[PoindexterOglethorpe]

21. Trust me, there is zero transparency about the cost of anything

in the medical world.

[El Mimbreno]

24. That's for sure

Once called a doctor's office and asked what the fee was for a basic visit. They didn't know! That's handled by their billing contractor. Imagine buying a car that way?