This week’s question from Dennis
Aaron, my wife has been told by the doctor’s office her Supplement is denying the Prolia injection she got a few weeks ago. My understanding from you was that when we switched from an Advantage Plan to Supplement N, this medication would be covered at 100%. So far it isn’t getting approved. Soon the second treatment will be due. What do we do?
Answer
It’s Not Possible for a Supplement to Deny a Claim
Dennis and his wife are clients of ours and he did exactly what we told him and every other client to do whenever there are issues such as: claim denials, bills that seem odd, expensive prescription costs, premium issues, or anything even remotely related to a policy we helped them enroll in.
The first thing I told Dennis was, “It’s not possible for a Supplement to deny a claim. I’m almost certain your wife’s doctor’s office made an error and what they told her was wrong.” As I’ve written on numerous occasions, Supplements have absolutely no say in what medical services or procedures are covered. None. In addition, providers don’t even bill Supplement companies directly. They bill Medicare, who then coordinates with whatever company the beneficiary has to get the provider paid in full. What gets approved is up to Medicare, who almost never requires prior authorizations for services. They trust the treating physician is qualified to decide what the best course of treatments are. This is probably the number one reason people choose to pay more for Supplements vs Advantage Plans because those with Supplements never have to wait for an approval to get a Prolia injection, an MRI, CT scan, outpatient surgery, etc. And those services can’t ever be denied. If the doctor wants his or her patient to have a procedure or test, it can be done the same day. If an attending physician thinks it’s prudent for a patient with a Supplement to remain an extra day or two in the hospital, it happens. There is never any interference from an insurance company.
It turned out I was correct, someone in the office made an error and decided it was Dennis’s wife’s Part D prescription plan, instead of Medicare, that should be billed. Although Prolia is a medication, when given by a doctor in an outpatient setting, it becomes a Part B Medical benefit and runs through Medicare. Dennis was correct that it would be covered at 100% with Medicare paying 80 and the Supplement 20. Almost all medications that are injected or infused at a physician’s office, medical clinic, or hospital are covered like this for those on Supplements. Please keep in mind that Advantage Plan HMO’s and PPO’s only cover 80% of the costs for chemo, Remicade, and other Part B drugs, with the patient responsible for the other 20.
This type of error and being given bad information by employees of a hospital or doctor’s office is extremely common. We are constantly helping clients straighten these types of issues out. There are so many different insurance companies and types of plans, it can be difficult for those without a lot of experience dealing with them all to keep up and understand.
Keep an Eye on your Billing
My advice is to never pay a bill when it even gives off a hint that it may be erroneous, or information given by a doctor’s office or billing department as 100% true.
And with prescription drugs, it’s also very important to investigate expensive charges at the pharmacy. Here’s why. The pharmacy employee who tells you what is owed generally has no idea why your medications are $573. They may have a hunch, but they don’t know for sure if it’s because your deductible hasn’t been met, if the drug isn’t on the plan’s formulary, or if it’s a Tier 4 medication that has a co-pay of 47% of the retail price. Why there isn’t technology or a computer program so it can be explained to the customer why their costs are what they are is beyond me. But the bottom line is all the person behind the counter is doing is relaying the charges on the screen he or she is looking at.
We instruct our clients to put the office numbers in their phone and never pay a large bill for their medications if they aren’t certain it’s accurate. Reach out to us first. We then call their Part D or Advantage Plan company with them to see what the issue is; If it’s the deductible that hasn’t been met yet, if it’s a Tier 4 or 5 medication, or if the drug in question is not on the plan’s formulary. We will ask what medications are covered that treat the same symptoms with lower tiers and co-pays, generics that aren’t subject to a deductible, or what other covered medications are on the formulary that might be a viable alternative. The client can then contact the doctor who prescribed the drug to see if a lower cost substitution is possible. It’s extremely common for a physician to call in a new script that can lower out-of-pocket expenses.
Thank you!
If you have any questions or concerns regarding this column topic, or would like to make an appointment for a no-cost consultation, please feel free to give us a call – we would be happy to help. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.
Erie County Area
1105 West 12th Street, Suite – A
Erie, PA 16501
Phone: 814-920-5275
Fax: 814-920-5276
Fayette/Westmoreland County Area
121 North Pittsburgh Street
Connellsville, PA. 15425
Phone: 724-603-3403
Fax: 724-603-3402
Pittsburgh Area
21 Yost Blvd., Forest Hills, PA 15221
Mailing Address: 128 Forest Hills Plaza, Pittsburgh, PA 15221
Phone: 412-349-8818
Fax: 878-302-3149
Albuquerque/Santa Fe, New Mexico Area
821 Coors Blvd. NW
Albuquerque, NM 87121
Phone: 505-200-0069
Fax: 505-200-0073
Serving These Areas
We proudly serve the health insurance and Medicare needs of the following Pennsylvania areas: Connellsville, Uniontown, Greensburg, Mt. Pleasant, Scottdale, Irwin, N. Huntingdon, Murrysville, Monroeville, Plum, Lower Burrell, New Kensington, Pittsburgh, Plum, Oakmont, Penn Hills, Forest Hills, Wilkinsburg, East Liberty, Lawrenceville, Bloomfield, Natrona Heights, Leechburg, Washington, Morgantown WV, Latrobe, Monnessen, Jeanette, Erie, Edinboro, Northeast, Girard, Fairview, Union City, Harborcreek, Corey, Meadville, Waterford, Ligonier, Kittaning, Somerset, Waynesburg, Fayette County, Westmoreland County, Armstrong County, Butler County, Somerset County, Erie County, Crawford County, Venango County, Allegheny Valley, Pennsylvania
We proudly serve the following New Mexico areas: Albuquerque, Rio Rancho, Sante Fe, Bernalillo, Belen, Los Lunas, Espanola, Moriarty, Corales, Tijeras, Cedar Crest, Edgewood, Soccoro, Sandoval County, Sante Fe County, Bernalillo County, Rio Arriba County, Valencia County, Soccoro County, New Mexico
Not affiliated with the U. S. government or federal Medicare program.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.