Our Client Service Team truly is this amazing when it comes to getting prior authorizations moved through the process. You can learn more about our Client Service Team and all the free services they provide our clients here: boomerbenefits.com/client-service-team/ 📌Our Client Service Team truly is this amazing when it comes to getting prior authorizations moved through the process. You can learn more about our Client Service Team here: boomerbenefits.com/client-service-team/ 📌Join our exclusive Medicare Q&A Facebook group to have your questions answered by Danielle and her team: facebook.com/groups/BoomerBenefits 📌New to Medicare? Attend our FREE Medicare 101 Webinar: boomerbenefits.com/medicare-101-webinar/
I have Medicare A, B and a supplement. My doctor performed a surgery which I assumed would be covered. Subsequently, the provider is billing me for the surgery. My Medicare Summary Notice indicates that my responsibility for this procedure is $0. When I asked the Medicare customer service rep why this would be, she said she guessed it was because it was the doctor's responsibility to get pre-authorization, and he didn't. Is this correct?
Hi Kevin - if the surgery was medically necessary, you should not be billed more than your deductible (depending on which Medigap plan you have), have you reached out to your provider to review the coding?
I have original Medicare with supplement G. I am trying to get surgery for a complete tear (off the bone). My surgeon tells me that recently many surgeries are being denied by insurance and I must go to physical therapy for six weeks first. if that is not satisfactory I can try to go for the surgery. I thought that original medicare allows the doctor to decide the best course of treatment. It is now three months since the injury and counting.
When your start your Medicare part A and B when you first turn 65 and you enroll in an Advantage plan and you later want to go back to original medicare with a supplemental plan is there a 6 month or 12 month trial right without answering medical questions ?.
Question. I'm turning 66 in January 2023, however, I have been on medicare advantage since I was determined to be disabled several years ago. So am I no longer able to switch from an advantage plan to different plan?
Hi Debbie, you are given a second 6-month Medigap Open Enrollment to apply for a Medigap plan without underwriting, which is based around your 65th birthday. If you are outside the 6-month window, you will likely have to answer health questions if you were to apply for a Medigap plan in most states. If you want to change Medicare Advantage plans, you can change Advantage plans during the upcoming Medicare Advantage Open Enrollment (January 1 - March 31). You can give us a call at 817-249-8600 if you would like to shop the plans in your area!
Medicare Part B may require prior authorization whenever you are administered a specific drug in an outpatient facility. Some medications require your physician to submit a drug prior authorization form, which your physician would provide. Once the form is approved, Medicare will provide its share of coverage.
Based on the "no surprises act" if you are on original Medicare doesn't the doctor's have to tell you that something is not covered? Last year my wife had a serious medical issue, several hundred thousand dollars. Medicare and our Plan G paid it all except the deductible. However, there was one thing that wasn't covered (for whatever reason), for several hundred dollars. Medicare ruled that we had a reasonable expectation that it would be covered, and were not told otherwise, so we were not required to pay it.
Hi Alan, The No Surprise Act requires private insurance plans to apply in-network cost-sharing for out-of-network claims for emergency care, prohibits providers from billing patients more than the in-network amount for surprise medical bills, and creates a process for plans and providers to resolve disputes about charges and payments. However, this is more directed toward private insurance as Medicare already prohibits this. Now, Medicare can deny a service if they do not deem it to be medically necessary. If you were to sign an ABN prior to a service, then you could be responsible for the cost because the provider is basically stating they don't think Medicare will cover the service. But, if you were not presented with an ABN, then it is possible Medicare can rule that you had a reasonable expectation it would be covered like they did in your situation. We're glad you were not stuck with the large bill!
I just had a "passionate" discussion with my insurance rep after she woke me up trying to instill fear on me about the dreaded pre auth aka WE want YOU to pay for it, not us. 20 year bloated documented history of taking medication. Over 1 million in back surgeries backed by the best surgeons, Doctors in my state. My rates have raised 2x/3x with less coverage yet she said my health was their main concern. No, your job is to shake as customers off their back so YOU can pay for it. Happy Holidays mini rant over.
In my case, it did. I had hip replacement surgery this year, and both of the surgery centers I was looking at called my Medicare plan G (Medigap) provider. In the first case, they called me back and told me I was NOT covered, because I was "out of network." I had to explain to them (the surgery center) that this was a Medicare supplement plan, and that they were required to cover the remaining cost of whatever procedure the Medicare covered. They eventually straightened it out, but their confusion was enough for me to lose faith in them, and I moved onto another surgery center.
It would be more so that Original Medicare would require it. Medicare Supplements cover any service that Original Medicare covers. Although Original Medicare is allowed to conduct prior authorizations, we usually see them in only a few circumstances. For example, Medicare Part B services may require prior authorization whenever you are administered a specific drug in an outpatient facility.
Our Client Service Team truly is this amazing when it comes to getting prior authorizations moved through the process. You can learn more about our Client Service Team and all the free services they provide our clients here: boomerbenefits.com/client-service-team/
📌Our Client Service Team truly is this amazing when it comes to getting prior authorizations moved through the process. You can learn more about our Client Service Team here:
boomerbenefits.com/client-service-team/
📌Join our exclusive Medicare Q&A Facebook group to have your questions answered by Danielle and her team:
facebook.com/groups/BoomerBenefits
📌New to Medicare? Attend our FREE Medicare 101 Webinar:
boomerbenefits.com/medicare-101-webinar/
I have Medicare A, B and a supplement. My doctor performed a surgery which I assumed would be covered. Subsequently, the provider is billing me for the surgery. My Medicare Summary Notice indicates that my responsibility for this procedure is $0. When I asked the Medicare customer service rep why this would be, she said she guessed it was because it was the doctor's responsibility to get pre-authorization, and he didn't. Is this correct?
Hi Kevin - if the surgery was medically necessary, you should not be billed more than your deductible (depending on which Medigap plan you have), have you reached out to your provider to review the coding?
I have original Medicare with supplement G. I am trying to get surgery for a complete tear (off the bone). My surgeon tells me that recently many surgeries are being denied by insurance and I must go to physical therapy for six weeks first. if that is not satisfactory I can try to go for the surgery. I thought that original medicare allows the doctor to decide the best course of treatment. It is now three months since the injury and counting.
We hate to hear this! You can see another doctor for a second opinion on surgery.
For outpatient hospital procedures, do we need a separate authorizations for the physician frm Medicare B and for the facility from Medicare A
It would depend on your facility - typically you should just need 1 approval if necessary.
Very interesting. I didn’t realize original Medicare had prior authorization. Thanks!
Happy to help!
This is so helpful!! Thank you for the clear explanations!
Glad it was helpful!
When your start your Medicare part A and B when you first turn 65 and you enroll in an Advantage plan and you later want to go back to original medicare with a supplemental plan is there a 6 month or 12 month trial right without answering medical questions ?.
Hi Santiago - When you use this Trial Right period, you have 12 months to go back to original Medicare and pick up a Supplement plan.
Question. I'm turning 66 in January 2023, however, I have been on medicare advantage since I was determined to be disabled several years ago. So am I no longer able to switch from an advantage plan to different plan?
Hi Debbie, you are given a second 6-month Medigap Open Enrollment to apply for a Medigap plan without underwriting, which is based around your 65th birthday. If you are outside the 6-month window, you will likely have to answer health questions if you were to apply for a Medigap plan in most states. If you want to change Medicare Advantage plans, you can change Advantage plans during the upcoming Medicare Advantage Open Enrollment (January 1 - March 31). You can give us a call at 817-249-8600 if you would like to shop the plans in your area!
Such a great topic to cover! Thank you for sharing your knowledge!
Thanks Alex!
I thought Original Medicare doesn’t need prior authorization if the procedure to be done by the doctor is an approved medical procedure by Medicare.
Medicare Part B may require prior authorization whenever you are administered a specific drug in an outpatient facility. Some medications require your physician to submit a drug prior authorization form, which your physician would provide. Once the form is approved, Medicare will provide its share of coverage.
AMERIKKKANAZI 🇺🇸 NEEDS " UNIVERSAL HEALTH CARE with DENTAL". for ALL in NEED ( Not WEALTHY People)!
We hear you! We hope Medicare will make changes to its dental coverage in the future.
this cleared up some things for me thank you!
You're welcome!
Thank You for this informative post. I appreciate you sharing your knowledge. All of this Medicare stuff is soooo confusing.
You're very welcome, Donna. We are always here and happy to help in any way we can! :)
More great information! Another thing to consider about using a Advantage Plan.
Glad it was helpful!
As a healthcare professional, I have not seen Medicare give a prior authorization for a procedure.
That's great to hear! But, since it is possible, we want to let our viewers know of the possibility of them running into this.
Based on the "no surprises act" if you are on original Medicare doesn't the doctor's have to tell you that something is not covered? Last year my wife had a serious medical issue, several hundred thousand dollars. Medicare and our Plan G paid it all except the deductible. However, there was one thing that wasn't covered (for whatever reason), for several hundred dollars. Medicare ruled that we had a reasonable expectation that it would be covered, and were not told otherwise, so we were not required to pay it.
Hi Alan, The No Surprise Act requires private insurance plans to apply in-network cost-sharing for out-of-network claims for emergency care, prohibits providers from billing patients more than the in-network amount for surprise medical bills, and creates a process for plans and providers to resolve disputes about charges and payments. However, this is more directed toward private insurance as Medicare already prohibits this.
Now, Medicare can deny a service if they do not deem it to be medically necessary. If you were to sign an ABN prior to a service, then you could be responsible for the cost because the provider is basically stating they don't think Medicare will cover the service. But, if you were not presented with an ABN, then it is possible Medicare can rule that you had a reasonable expectation it would be covered like they did in your situation. We're glad you were not stuck with the large bill!
Do you offer help with ACA registration ?
Hi Mark, we only specialize in Medicare plans!
I just had a "passionate" discussion with my insurance rep after she woke me up trying to instill fear on me about the dreaded pre auth aka WE want YOU to pay for it, not us. 20 year bloated documented history of taking medication. Over 1 million in back surgeries backed by the best surgeons, Doctors in my state. My rates have raised 2x/3x with less coverage yet she said my health was their main concern. No, your job is to shake as customers off their back so YOU can pay for it. Happy Holidays mini rant over.
Yep prior authorizations are very frustrating
Does this hold true for Medicare Supplement plans as well?
Of course it does because the supplement won't cover the 20% unless medicare covers the 80%
In my case, it did. I had hip replacement surgery this year, and both of the surgery centers I was looking at called my Medicare plan G (Medigap) provider. In the first case, they called me back and told me I was NOT covered, because I was "out of network." I had to explain to them (the surgery center) that this was a Medicare supplement plan, and that they were required to cover the remaining cost of whatever procedure the Medicare covered. They eventually straightened it out, but their confusion was enough for me to lose faith in them, and I moved onto another surgery center.
@@georgegravette1132 Oh, the stories we could tell! It is terrible to have stressful health issues compounded by confusion and incompetence.
It would be more so that Original Medicare would require it. Medicare Supplements cover any service that Original Medicare covers. Although Original Medicare is allowed to conduct prior authorizations, we usually see them in only a few circumstances. For example, Medicare Part B services may require prior authorization whenever you are administered a specific drug in an outpatient facility.
Thanks for uploading!! You need to research Promo SM.
You bet!