Medicare denial of some of the charges for my Ablation

I have just received a copy of a letter sent by Centers for Medicare Services to Charleston University Medical Associates denying their appeal for some of the charges for my ablation. In this letter they reference a "claim for the 93657 (insertion of catheters for treatment of abnormal heart rhythm) provided on January 23, 2014." The letter states: "The charge was denied on March 04, 2014, because the level of service was excessive." The denial of the appeal states that "the claim is not covered by Medicare."

The letter also states they cannot bill the patient for the appealed service.

Even though the Medical University will not be allowed to bill me, it concerns me that Medicare would deny this portion of the procedure. How can Medicare determine the level of service was excessive when ablation requires insertion of catheters to perform the procedure? This letter doesn't mention the Affordable Care Act, so I don't know if this decision is based on the new law or if this is previous law.

I really hope the Medical University of Charleston will request an independent appeal and succeed. I'm concerned that quality doctors are going to start denying expensive care for Medicare patients if some of the reimbursements are denied. Already, doctors who accept Medicare patients have to accept reduced payments for their services.

Has anyone had this experience with their ablation charges?



Edited 1 time(s). Last edit at 05/03/2014 01:24AM by Jean.

All that's needed is an exemption.

[danfromsquirrelhill.wordpress.com]

The claims in the above link have hypertext links to reliable sources such as The New York Times, The Washington Post, Forbes, etc., so independent verification can be made to determine if the blogster got the facts correct.

From the above link, this one I'm ok with: "235) Obamacare requires pizza restaurants to post the calorie counts for 34 million different combinations of pizza toppings" since I'm already getting bad vibes about gluten-containing products and I'm only 90 pages into this: [www.amazon.com] . I doubt I'll be needing to read pizza-calorie-count information after finishing the book.



Edited 3 time(s). Last edit at 05/03/2014 12:56AM by morpheus.

Jean:

Do you have Medicare Advantage, I understand they are bad with paying costs and don't cover many things, do you also have supplemental health ins., which pays 20% of your health care costs?

I have read some of what Morpheus posted, it is a book, but, he doesn't have to convince me, I was, am against this bad law. People should read, at least as much as they can..

Liz

Liz, I have original Medicare and supplemental insurance. I wasn't charged anything for the ablation, but I just hate to see the doctors and hospital be denied some of their expenses when they already have to take a reduced payment for their services.

Jean



Edited 1 time(s). Last edit at 05/03/2014 01:26AM by Jean.

Health insurance providers now have a captive audience. The stockholders in those companies will expect yearly increases in both stock value and in dividend payments. The typical ways to increase profit, and thus enhance stock value and insure the availability of funds to distribute as dividends, are to raise monthly premium rates each year or to reduce services, or both.

Increases in monthly premium rates may take the overt form of visible increases such as going from $300 a month to $350 a month. If one sees that their monthly rate for a given year hasn't changed then there is likely to be modifications in the plan such as increasing the deductibles, increasing the out-of-pocket expenses, moving tier I drugs to tier II, moving tier II to tier III, etc., delimiting certain services that formerly were covered. Or all or some combinations of those steps. It will happen under the ACA to a greater extent than before ACA.

Doctors associated with particular HMO's, etc. who are determined by those HMO's to be among those doctors who prescribe the greatest number of diagnostic tests and procedures will be told to limit them or be expelled as a plan doctor. Those doctors who comply with the HMO's dicta will decrease the number of tests and procedures that they prescribe for their patients, thus possibly causing harm to those they otherwise would have prescribed for. Since the total number of tests and procedures will have been reduced by the complying doctors a new metric for prescribed tests and procedures will have been established for the coming year. It can be seen that the new standard of the number of tests and procedures will include some doctors who were formerly in compliance with the HMO directives, but now won't be in compliance. They will now be among those doctors who prescribe too many tests and procedures. They will receive a letter. The same logic applies to hospitals that are "preferred" by the HMO's. You can easily see where this is going.

Already we have seen government panels suggest both modifications to the frequency of mammograms as well as upping the age for initiating them.

If you like your current plan you can keep it, right?


And now a PS as my 8th edit (I think, lol)

PS: our representatives neither write nor read the legislation they enact. HMO's?, they were potrayed to be the bad guys (and they are) in order to serve as a whipping boy for the public to rally against because they, the HMO's, "opposed" the ACA. HaHaHa, the "demon" HMO's and health care providers **wrote** the law for their own benefit by way of their lobbyists. I wish I could get the government to mandate that all citizens **must** order pizza from my store! Oh, well maybe not pizza.



Edited 8 time(s). Last edit at 05/03/2014 12:45AM by morpheus.

Wow! Do you folks watch Fox News? A few years ago I would have written a long insulting diatribe, but now I'll just say Wow!

morpheus pandiculates



Edited 1 time(s). Last edit at 05/03/2014 01:43AM by morpheus.

“Wow! Do you folks watch Fox News? A few years ago I would have written a long insulting diatribe, but now I'll just say Wow!”

Never before have I seen such a brilliant point-by-point excoriation of asseverations apparently considered to be contra-factual. Every single nuance examined in minute detail and then proven to be lacking in truth-value. Clearly, an unparalleled tour de force for which there can be no viable refutation. A masterful blend of both exegetical and eisegetical elements welded, undoubtedly, by the unfathomable mental depth of a singular intellect.

Bravo!

Or should it be “Brava!”? Enquiring minds want to know. (Note to the readers of this: be sure to put an emphasis, by way of rising tone and clipped enunciation, on the final “a”, if “Brava!” turns out to be operant, much as Jack Nicholson did in “The Witches of Eastwick”). [www.youtube.com] Note also, that Nicholson, in the first part of that clip is making a prescient, if anachronistic, comment on a particular "Wow!" post found here.

And now, I need to resume writing the essay mandated by my employer: “On the eschatological implications of a presumed rectitude of the doctrine of apocatastasis”. If it isn't in by the next esbat I'm required to attend, there'll be all hell to pay, so to speak.



Edited 6 time(s). Last edit at 05/03/2014 05:03AM by morpheus.

Morpheus,

As a fairly new poster, please be aware that politic debate is not supported on this forum. There are thousands of fire-breathing political wrangling sites for those who wish to turn topics into whipping boys for a given polarized position, which ever side of the coin that might represent, but here we wish to keep the focus on AFIB and issues more closely related to dealing with aspects around managing this challenging condition without getting folks too riled up over such positions and projections. Thanks for honoring that basic rule for the road here, as noted elsewhere on this website within our guidelines for posting.

And Jean and Liz, just to address your question, Jean's issue with her Medicare-based insurance not reimbursing a part of her ablation has Zero to do with Obamacare, Rush Limbaugh or the Pope for that matter, regardless of how tempting any such figures might appear to be as a scapegoat.

This scenario Jean seems to be referencing had first become a problem late in 2012 into the first half of 2013 last year that has largely been fixed in most parts of the country already from my understanding when a Medicare and CMS new rule went into effect without warning or discussion between those entities and care givers and hospitals In which CMS suddenly and rather arbitrarily started to deny payment for any aspect of an ablation beyond a simple PVI, and all based on changing which billing or CPT codes could be used for different aspects of the ablation procedure.

It threatened to become a real problem for all of us requiring more extensive ablations beyond just a boilerplate PVI, but has since been sorted out with the proper codes being clarified for more extensive ablations required to get reimbursed properly. It is my understanding that most centers and EPs seem to be aware of these new codes and procedures for proper reimbursements by now.

And this was all well before any implementation of the Affordable Care Act which was unrelated in any event as this was all simply an internal billing adjustment snafu within CMS which is the regulations and billing arm of Medicare.

And Jean, it could be that since your long 7 + hour procedure that was quite unexpected, as noted by Dr Wharton in his ablation report when he discovered you needed far more work than he originally imagined would be needed, that perhaps some of the coding applied to some of the added features of your more extensive ablation were not yet in sync with the new regulation codes required for automatic reimbursement of those aspects of your ablation to happen without this kind of hitch?

In any event, this is a good example of why political discourse is not welcomed here, so that basic questions or comments around one's AFIB related experiences are not inadvertently hijacked by ideas that seem to imagine whatever 'devil' may be in the White House or in control of congress at any given time must obviously be responsible for whatever the problem being discussed might be, and regardless of how seemingly 'obvious' or 'off the wall' such guilt might appear to the person sharing them here, or to the rest of our readers.

Many folks have written to us over the years how much they dislike overly argumentative and/or polarized politicizing of topics here when this message board has been dedicated and so focussed on remaining an open and welcomed oasis for people of all persuasions and belief systems to come to for help, guidance and for each to share their own pearls of wisdom learned in their own battles around living with this beast of a condition with the rest of us. As such, we will strive to keep the welcome mat open to all who strive to play by our short and sweet guidelines of remaining courteous and respectful in their discourse and while avoiding politically or religiously charged debate. In addition, since this is not the place for overly argumentative debate when two of more people lock horns too strongly to the point of negative personal comments and disrespect start to take over, that too isn't welcomed here as well while we are reviewing our few rules of the road. AFIB is a tough enough topic without subjecting each other to any of those kind if emotionally charged distractions ... Outside of those minimal boundaries free speech is wide open and welcomed here.

And this should not put too much of a crimp in any afibbers desire to vent their politic feelings and projections since the web is full of so many alternative posting sites and blogs for them to have at it to their hearts content with others over whatever politically-oriented injustice or outrage is being assumed or discussed.

Many thanks,
Shannon

Shannon,

I'm sorry that I posted my experience. I did not post this information to start a political discussion. I was and am genuinely concerned that a portion of an ablation expense could be denied. My concern has nothing to do with politics. I was simply interested in others' experience with Medicare and whether their provider had been denied a portion of their ablation expense. Thanks for your explanation and please just delete this post.

Jean

Sorry, I was being mordant as is my wont. Definitely off topic. My excuse, as always, is: "The devil made me do it".

Hi Jean,

No worries at all, I realize that was not your intent at all and that your comment and concern expressed is perfectly fine, no need for deletion. I just wanted to clarify the issue for others and for readers as well who may new here and perhaps are not as aware of the ground rules regarding political and religious debate while this topic was active and provided a good example of why we would rather keep it simple and not delve into the emotionally charged polarizing topics that are so popular yet. alas, so often confronting and combative these days. For so many topics these days, people who are so married to a given viewpoint on one side or the other of the political fence ( or better yet brick wall), tend to almost automatically presume and see a political cause to most every issue .. and not surprisingly the problem is almost always with the 'other guy' ... :-) There is no end to it once the gloves are taken off on that sort of discussion so we just prefer to nip it in the bud here and get back to the business at hand.

Better to steer clear of those minefields is our motto. But your issue with the reimbursement is a valid concern of course, though I imagine the hospital and Dr Wharton's office will get it worked out with CMS and Medicare over time, or at least I hope so. This issue was a hot topic a year ago among EPs and hospitals when it seemed suddenly Medicare was becoming far too intrusive into the medical decision making during an actual ablation, when it was really mostly just a matter of misunderstanding requiring clearing up billing codes to be more flexible in what is allowed for billing.

Dont be sorry at all Jean, it was good that you brought it up.

Cheers!
Shannon

Hi Morpheus,

No problem, I realize you are still a relative newbie here as they say. Just wanted to make sure you, and other readers who may have been unaware, were clear and up to speed on the score for welcomed posting here.

Cheers!
Shannon

My two ablations had several charges refused by medicare, including those for a second doctor who seemingly was there as a student. Since most of the ablation patients are likely on medicare, and most ablationists don't refuse medicare,,,I'd bet they're still making some profit :-), as is the facility that houses their procedure.

"and supplemental insurance"

What supplemental insurance? That may be key. I had an ablation at Mass General Hospital October 2012 with Medicare and Blue Cross Medex (at $200 a month) that cost me zero $$s.

I had a second Ablation on Feb 21 2014 At Montefiore In the Bronx.

I thought I noted the same rejection on my EOB. I can not find it at this point.
I do note the approval of the insertion of three catheters.
I had four inserted.
So there may be one I cant find.

Jim B.

this last post has me wondering if insurance is often denied when it's a second ablation...is that to be expected? I would hope the insurance company realizes that a second Ablation is often needed....as will be true for me, and many others.

Barb

I must answer that Medicare has given me the least hassel of any medical insurance I have ever had. When I worked and had commercial insurance it was a constant hassel. 50% of the claimes were rejected, necessitating calling, providing documentation to the insurance Company and reevaluation on thier part.
(If the HR department ever took into account the lost job time they would have gotten a better plan.)

With Medicare and a supplemental Insurance, my yearly out of pocket, expenses have disappeared.

In this case I think the use of 4 catheters was unusual and I am sure that the hospital will sort thing out after a while.

they usually do.

I agree that Medicare with a good Medicare supplement plan filling in the gaps has been great for me as well paying almost everything for both ablations with Dr N plus the Lariat procedure as well as 14 separate Electro-cardioversions before my LAA isolation eliminate the need for any more sudden zaps at the ER at roughly $7,500 a pop for actual billing charges by a given hospital ER for a walk in ECV.

Shannon

That is true for right now Shannon, but for how long, there has been 700 billion dollars cut to Medicare, entitlements are draining our country.

L

Jim and Shannon, that's been my experience too. With Medicare and BC/BS Medex, I have had zero medical bills for anything, and that included a hernia operation that needed a couple of pain clinic visits afterwards. Whatever Medicare doesn't pick up, the Medex plan does. A giant improvement over BC/BS alone. And no need of any referrals. I go to some of the best docs on the planet at Massachusetts General Hospital if I feel I need to (such as with the peripheral neuropathy I suffer from).

How long this will last with the changes in healthcare, who knows.

The charges for my overnight hospital stay after my ablation were denied and deemed unnecessary.
The reason given is that most ablations do not require an overnight stay and my blood pressure, breathing and other vitals were all normal. I guess I should have just got off the gurney nauseous as I was, bled out from groin sheath insertion sites and passed out. Now that's what I call clueless at St Luke's.


McHale

McHale, how can they maintain medically unnecessary? Is it true that "most" ablations do not require overnight stay?
I know all the ablations at Mass General have an overnight stay. It's their EP Lab policy. What insurer?

McHale Wrote:
-------------------------------------------------------
> The charges for my overnight hospital stay after
> my ablation were denied and deemed unnecessary.
> The reason given is that most ablations do not
> require an overnight stay and my blood pressure,
> breathing and other vitals were all normal. I
> guess I should have just got off the gurney
> nauseous as I was, bled out from groin sheath
> insertion sites and passed out. Now that's what I
> call clueless at St Luke's.
>
>
> McHale

Wow....

Medicare paid for both my ablations, including the overnite stay. I've never heard of an ablation without overnite stay, it is SOP for most. Were you using a private insurance?

That is totally bogus McHale of your insurance company and completely indefensible, I would fight that tooth and nail. Ive never heard of an AFIB ablation as a same day surgery release. If they claim 'most ablations' are done that way, have them prove it statistically. They will not be able to do so and will fail miserably.

It would not be hard at all to call the top 30 AFIB centers in the US and get confirmation that every single one of them requires an overnight stay to their AFIB ablations.

Shannon