What if your doctor recommended some expensive blood tests that Medicare would not cover? . That’s what happened recently to Kim Hanks. Unfortunately, she didn’t find out until after her blood tests were complete that Medicare would not pay for them.
This Medicare beneficiary says she’s left with a $732 blood test bill, and she hopes Consumer Rescue can help.
Hank’s experience serves as a cautionary warning for all Medicare beneficiaries.
Just because a doctor or other provider suggests a test or procedure doesn’t mean Medicare will pay for it. Ask your doctor some questions. Primarily, you need to know if Medicare will consider them “medically necessary.” If not, you, like Hanks, could be on the hook for an unexpected bill.
Doctor-recommended blood tests
During a medical visit, Hanks’ doctor suggested some blood tests which could be done at a lab conveniently located nearby. The lab drew the blood, did the tests, and submitted the bills to Medicare.
While Medicare Part B and her Medicare supplement plan covered the doctor’s visit and many of the blood tests along with the 20 percent copay, it denied coverage for six of the tests the doctor ordered. That left her with that $732 bill.
I signed an Advanced Beneficiary Notice (ABN) when I visited (the medical practice). (They) miscoded lab tests done by (the lab) and so my insurance, Medicare and Anthem Blue Cross, denied the claims. The doctor’s office claims it doesn’t have to correct the coding because of the ABN and the lab claims it can charge “anything it wants” because of the ABN. Is this correct? I feel I’m being lied to and taken advantage of. $732 is at stake.
Hanks was angry, as most of us probably would be if we were hit with a large unexpected bill. However, Medicare rules are complicated. Procedures that you think will be covered often aren’t. That’s the case here. Let’s start by looking at the notice she was asked to sign.
What is an Advanced Beneficiary Notice (ABN)?
If you have Original (fee-for-service) Medicare, a doctor or other provider will ask you to sign an ABN if they know or think that some of the services they’ll provide won’t be covered. You have three options if you are asked to sign one:
- Get the services and ask that the charges be submitted to Medicare while agreeing to assume financial responsibility if Medicare does not approve the charges. If Medicare denies coverage, you will have the right to appeal.
- Agree to pay the charges without them being submitted to Medicare.
- Decline the services in question.
You can find a more detailed explanation of the ABN and your rights on the Medicare website.
Many medical practices will ask a patient to sign one as a routine matter, especially if the patient is new or is having some kind of outpatient surgical procedure.
Did the doctor make a coding mistake?
We don’t know whether Hanks’ doctor thought a specific blood test might not be covered. I’ve found that doctors often don’t have a good understanding of Medicare rules. If you are asked to sign an ABN by your doctor or other provider, it’s OK to ask what particular services may not be covered.
Did Hank’s doctor miscode the lab tests, as she claims? I would be surprised if that were the case. The doctor wrote the lab order for specific tests and the lab did the requested work. The lab can indeed charge whatever it wants for blood tests. However, since the lab agreed to bill Medicare, it has to accept Medicare’s contract rate as total compensation for covered services. But the lab can charge patients its going rates for services that insurance does not cover.
Hanks’ doctor declined to change the coding on the lab order. The real issue is not whether the codes were correct, but rather whether the doctor could honestly show that the tests in question were medically necessary.
Warning: Medicare doesn’t always cover blood tests
Sometimes, Medicare will cover blood panels and specific tests under certain conditions while it denies coverage for those same tests under other circumstances. There are several factors that come into play, but the key factor is medical necessity. For many of them, the doctor has to make a case that the test in question is medically necessary to confirm a diagnosis or to manage a specific condition for that particular patient.
Let’s look at one of the tests Hanks’ doctor ordered – one that checks vitamin D3 level. That test might be covered if the doctor needed to confirm a diagnosis of a D3 deficiency, which she does not have, or to treat specific conditions (listed on the Center for Medicare and Medicaid Services [CMS] website) which she also does not have.
All of the other denied tests, except one, had similar conditions attached. The exception was a test that Medicare does not cover at all and for which the ABN is required.
Doctors don’t know everything (and I mean no disrespect)
I once had a specialist suggest a blood panel that included a D3 screen. When I asked if he thought I might have a D3 deficiency, he said no but that it would be worth just checking. I asked him to not include that in the lab order and explained why.
In my role as a registered Medicare counselor, I met with a woman who wanted to appeal a Medicare denial of a certain blood test. When I read her the CMS requirement that the test has to be related to a specific condition, she understood right away because she was a retired nurse and was knowledgeable about that condition.
If a doctor suggests a blood test and uses terms like “routine” or “just to see,” ask why they think it’s medically necessary. Remember, that’s what Medicare will consider in deciding whether it pays — or you pay.
Read your Medicare Summary Notice
After a doctor or other provider submits a bill to Medicare for services for you, Medicare will notify you via a Medicare Summary Notice (MSN). It will summarize all of the services billed to Medicare by your doctors and other providers. It will show the provider, the amount billed, whether Medicare approved the charge, the amount Medicare actually paid, and the maximum amount you might owe. If you are in a Medicare Advantage (Part C) plan, the notice you get is called an Explanation of Benefits.
You can view the MSN in your Medicare.gov account or have it sent to you by U.S. Mail.
It’s important that you read it. Hanks apparently did not read hers. If she had, she would have seen that Medicare did not approve coverage for certain tests and each denied charge would show a code and notes explaining why.
Remember, if Medicare does not approve a charge, your Medicare supplement plan will not pay either.
I’ve written about other Consumer Rescue readers who got hit with surprise bills for services that Medicare did not cover in this article, and where I also explained how to read and understand the MSN.
I told Hanks that she had the right to appeal the Medicare denial. She said she had already done so and is awaiting the response. Unfortunately, I had to tell her that, in my opinion, her appeal would unlikely be successful.
Avoiding problems
It’s important that you understand the specific tests your doctor thinks you should have. If it’s not urgent that you get to the lab the same day, take some time to do your research. The official Medicare website has a search function to see if a procedure is covered. You can also do an online search of “Does Medicare cover the _________ test?” The results will often include links to the CMS pages that detail requirements for payment.
Medicare coverage rules can be confusing.
A great source of free, unbiased and knowledgeable Medicare information is the State Health Insurance Assistance Program (SHIP). It’s federally funded and available in every state.
Of course, you can also submit your Medicare questions to me here at Consumer Rescue.
Watch Out for this “Not Junk” mail
In the next few weeks, all Medicare beneficiaries will be getting an important piece of mail that may look like junk mail but that you must read.
It’s the Annual Notice of Change that all Medicare Advantage and Medicare prescription drug plans are required by law to send in advance of Medicare’s Annual Enrollment Period (Oct. 15 – Dec. 7).
Watch for my upcoming article on why it’s especially important this year to pay attention to that notice. (Abe Wischnia, Special features columnist, Consumer Rescue)
