Jump to content

Medicare/Tricare for Life Payment Question


DJW

Recommended Posts

So the DW has her follow up with her new Medicare Doc after her labs etc. This was not the initial appointment with the Doc but the follow up to that appointment after all the labs results were back. The Doc says your cholesterol is a little high, not over the top high just a little high. They have this test where they take a picture of the heart and they can see if there is any blockage. She says insurance won't pay for it but they the hospital has a flat rate fee of $50.00. My question is if Medicare will not pay for it will our Tricare for Life? I thought that what ever Medicare would not pay for Tricare for Life would?

 

Dennis

Link to comment
Share on other sites

If your wife is on Tricare for life then Medicare is the first payer. The remaining bills go to Tricare who then pay. If your are using Dr and hospital that are part of Medicare then they can not by law charge you anything else. I can't imagine any legitimate test that Medicare wouldn't cover unless...and here's the caveat...she does not have a diagnosis to support the test being done. If that's the case then neither Medicare or Tricare are going to pay.

An example is that Ron has very normal cholesterol. So even though he does have a heart issue, it is not related to any types of heart disease that cholesterol affects. Therefore Medicare does not pay for an annual cholesterol screening. If we want it done then we pay or he gets it done at VA.

So if she can have it done for only $50 and it gives her peace of mind then its selfpay

Hope I didn't confuse you. You might ask the Dr billing people if they have a better diagnosis code that would apoy to her and thus cover the cost

Link to comment
Share on other sites

Just an added reminder for clarity. Under TLC. If Medicare doesn't approve and pay then neither will Tricare. When it comes to tests its always best to make sure.

Also for other issues remember this

Medicare only covers a hospital stays of 24 hours or longer. If you are admitted for observation only the clock starts when you are actually admitted. It doesn't count any time spent in the ER

Link to comment
Share on other sites

Hi, don't understand the part about cholesterol screening not being covered, mine is tested every year during my annual physical along with other blood work. It has always been covered/paid by Medicare/TFL

BobQ

It is all about your diagnosis code from your physician. If you have elevated cholesterol or any other diagnosis affected by cholesterol then Medicare will cover it as part of your annual. In Ron's case since none of his diagnosis relate to elevated cholesterol and his is vell in the normal range then Medicare does not cover it. Believe me we have been down this road and ended up paying for it. You always sign a document and the fine print tells you that there may be tests ordered by your physician that are not covered and that you will be financially responsible.

Link to comment
Share on other sites

Medicare pays for the blood work.
Supplemental Insurance never has to pay anything on blood work.

Medicare has payed for twice a year test for me. Both done from a prescription from the doctor.
Some are different test ask for each time.

Fall
Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets)
Blood Test, Comprehensive Group Of Blood Chemicals
Hemoglobin A1c Level

Spring
Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test
Blood Test, Comprehensive Group Of Blood Chemicals
Manual Urinalysis Test With Examination Using Microscope
Blood Test, Lipids (Cholesterol And Triglycerides)
Urine Microalbumin (Protein) Level
Creatinine Level To Test For Kidney Function Or Muscle Injury
Hemoglobin A1c Level
Blood Test, Thyroid Stimulating Hormone
Prostate Cancer Screening; Prostate Specific Antigen Test (Psa)
Creatine Kinase (Cardiac Enzyme) Level

Link to comment
Share on other sites

Obviously Biker YOU have a correct diagnosis code for YOUR labs so Medicare pays.

 

My point is that with out a pertinent diagnosis code Medicare would not pay, especially for a routine cholesterol screening after the first one and so neither will Tricare. Other supplements may have different co pay rules.

 

All insurance companies need a reason (medical diagnosis) before they will pay for anything. The first annual screening under Medicare usually pays because its a screening. After that it can be a crap shoot if the ordering physician doesn't code the lab orders correctly

Link to comment
Share on other sites

Archived

This topic is now archived and is closed to further replies.

Guest
This topic is now closed to further replies.
×
×
  • Create New...