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Medicare Annual Exam and Federal Employees Health Benefits Coverage...Please read.


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This question is for Federal employees that kept their health insurance into retirement.

I had a "Medicare" physical a couple of years ago.....NEVER AGAIN.  Last fall, I went to see my doctor for my annual physical and said I want my regular annual physical NOT the Medicare physical.  She said, that my insurance might not cover it.  

I said...Nope, they will cover it.  Page 38, line 14 on coverage for physicals...One annual physical without copays.

Guess what, they did not pay it.  Well, they partially paid leaving me on the hook for $51.  

As I started asking questions about WHY they didn't pay the full amount the answers got weird and I got the distinct impression there was some high tech fraud going on.

I did contact the Washington state Insurance Commissioner and was told yes I have a case, but because of the Constitution they were TOLD by the Federal government to butt out of Federal Health Insurance issues.  He recommended that I contact the Washington state Attorney General's Office on Consumer Fraud since that is a separate isssue. 

The Attorney General's office is willing to take the case, based on initial information.  But they asked me to find OTHER Federal employees that have had the same issue.  

I briefly talked to two friends that have had the same issue.  They also have the same health insurance.

Won't use your name, but I would be interested in a count of how many Federal employees have faced the same issue with regard to Medicare physical exams.

Besides the fraud aspect, there is also a age discrimination complaint since ONLY folks over 65 have to pay for the medical exam in spite of the Federal contract with the insurance company.

I also opened a complaint with the Inspector General's office about the fraud aspect.

Thanks.

PS...long thread, that is worth reading if your a retired Federal employee.  I still would like to hear from those folks that ran into the same issue.

 

Edited by Vladimir
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There is a difference between a yearly "wellness visit" and a physical.
https://www.medicare.gov/coverage/yearly-wellness-visits

"If you’ve had Medicare Part B (Medical Insurance)for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease and disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam."

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It is NOT about Medicare...it is about the FEHB program.

I did talk to somebody in Medicare and they looked at my bill.  Medicare DENIED the ENTIRE claim.  They said it was not a physical exam on the coding.  In fact, she didn't know what it was so they just denied the entire claim.

I specifically, said I wanted a "physical exam", yet they coded it as something else.  It goes to Medicare simply because it is the primary. 

The FEHB health insurance is the SAME HEATLTH insurance as I had when I was working.

They payed for the physical then.  Their contract has NO EXCEPTIONS for Medicare eligible folks.

By the time I got done collecting information there were so many RED flags that I felt I was back in the Soviet Union!!!

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20 minutes ago, pjstough said:

So what health insurance do you have?

What is your co-pay for doctor visits?

GEHA.

No copay.  I have Medicare, Medicare part B, and the SAME Federal Employee Health Plan that I had when I working.  I am well over insured on the medical front.

 

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Posted (edited)

Here are the RED FLAGS that came up on my long, strange trip through the medical billing system.

First, when I insisted on my previous standard physical exam.  I was told that my insurance would not pay for it.  No problem, I said I have a copy of the contract.  Page 38, line 14 GEHA will pay for ONE physical with NO COPAYS.  So the clinic KNEW beforehand.

When I got my bill I called GEHA and asked why they didn't pay the entire amount.  The friendly, helpful lady looked it up and said "you were outside our preferred provider network". 

That got my attention.  The Clinic is the ONLY medical provider for 150 miles.  So if they are out network, I am out of GEHA. 

She looks up billing and asks which address did you get treatment??  I said it didn't matter the Clinic owns everything in the valley.  Well, she said it shows the SAME CLINIC with two address, one in the preferred provider network and ONE OUTSIDE.  I told her the address outside the network is where I just had a 4,000 dollar Colonoscopy and GEHA PAID EVERYTHING.

She tried to FIX it, but couldn't since that required a SUPERVISOR.  I asked her to have the Supervisor call me back when it was fixed.  In two weeks, the Supervisor called back and said they were NOT going to change my billing.

I called Medicare and talked to a representative there.  They DENIED the entire claim, because they didn't know what the billing code was!!!  Medicare isn't involved.  It is a question of GEHA insurance.

There is also the issue of age discrimination. 

Before I turned 65, with the SAME GEHA medical policy, same Dr., and same address and same physical GEHA paid in full without a copay.  Once I turned 65 I was on the hook for $51 according to GEHA even though there is NO MENTION of it in the contract.  That is a pretty clear case of age discrimination in my book.

I talked to a couple of friends, one in California and the other in western Washington.  Both ended with the SAME $51 charge for their physicals.  It is a system wide problem.  All you have to do is take the number of Federal retirees over 65 with GEHA and multiply by $51.  THAT IS A LOT OF MONEY.

There is the issue of how much is GEHA fraud and how much is the local Clinic.  I can't sort it out, but am pretty sure the Attorney General's office can get to the bottom of it.

Hope this helps other folks.  BTW, I would be curious if other Federal insurance providers had similar problems with this physical exam.  So far the answer appears the issue lies with GEHA.

 

Edited by Vladimir
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I have GEHA high option as a single. Since I go VA I have not had a physical or wellness check since late 90's so I can not say. One thing you state is about the coding. If the Dr and or lab doesn't code  correctly they will not pay correctly.  I have GEHA dental and I ran into some payment issues that were caused by the people inputing the information did not know what they were doing and it took forever to get it straightened out. I don't know if this has caused your issue but I suspect it is at least part of the problem.

I am not service connected vet so GEHA picks up a part of my copays and the billing to GEHA has caused issues.  I am not nearly as happy with GEHA overall as I used to be just as an informational asside.

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26 minutes ago, Vladimir said:

GEHA.

No copay.  I have Medicare, Medicare part B, and the SAME Federal Employee Health Plan that I had when I working.  I am well over insured on the medical front.

 

So how did GEHA code it on the EOB, and what all did the EOB say?

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GEHA coded it as WACO.

It is not an ERROR.  Remember I made a HUGE deal about having my STANDARD physical.

The other issue, is when the Supervisor called me back I asked what WACO stood for.  She said under HIPA rules she could NOT tell me what it meant. 

Basically, GEHA sends out a explanation of benefits that is total gibberish on purpose.  THERE IS NO MENTION, about the bill not being paid in full because the address was not that of a PREFERRED PROVIDER. 

That would lose them a whole mess of clients during next open season.

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Vlad your last post was while I was typing - also pistough.  After you post I lean more toward you are dealing with some nice people who don't fully know what they are doing from the Dr office on down.  I think this is more common during and after covid situation..    I still get most of meds from GEHA/caremark mail order. If I do it on line it almost always gets screwed up and they make it somewhat difficult to get to a person on the phone but I have learned to always do so if I want to come close to getting it right.  One issue is when I have annual renewals there is one I don't want shipped until I know I will be somewhere to get it easily as it is shipped in cold pack. The last 2 times even with verbal and printed instructions they have shipped it anyway and I was lucky enough to get it. Of course it starts with getting the prescription right in the first place from the Dr.

As I understand since you are on medicare you are not required to use the preferred provider network in the first place which again leads me to believe it is at least partly due to someone at GEHA not knowing what they are doing completely.

IE: where I am volunteering with USFS we have a new employee on the front desk. Seems good and smart but no way can she answer questions with knowledge as she came from the heart hospital and barely new where the District is. If she stays she will probably be good.

Edited by bigjim
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No....the billing address is a clear case of fraud, in my opinion.  The fact that a Claims Representative could NOT fix it, and a Supervisor did NOT want to!!!  In fact,  when I complained to the Supervisor that it looked like fraud, she just laughed and said YOU HAVE to file an APPEAL with GEHA and WE will decide.

The EOB is sent to the client to the client, without ANY explanation, and most people just pay it.  Like my friends.

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4 minutes ago, Vladimir said:

and a Supervisor did NOT want to!!!  In fact,  when I complained to the Supervisor that it looked like fraud, she just laughed and said YOU HAVE to file an APPEAL with GEHA and WE will decide.

That sure says a lot and I am not at all surprised. 

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3 minutes ago, pjstough said:

So did the EOB show what the doctor charged for the physical, what the insurance company allowed, and then what was left?

The amount billed was $404.00.....the amount allowed was 353.00....GEHA plan payments were 353.

Remember, GEHA was suppose to pay IN FULL for a anuual physical exam with NO CO-PAY according to the contract.

 

 

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25 minutes ago, bigjim said:

As I understand since you are on medicare you are not required to use the preferred provider network in the first place which again leads me to believe it is at least partly due to someone at GEHA not knowing what they are doing completely.

IE: where I am volunteering with USFS we have a new employee on the front desk. Seems good and smart but no way can she answer questions with knowledge as she came from the heart hospital and barely new where the District is. If she stays she will probably be good.

When somebody makes a mistake it is usually limited to ONE person and ONE item.  Mistakes are fine, everybody makes them.

However when........

The Doctor know there is going to be a problem with your medical claim.  Red flag one.

When your billing is miscoded?  Red flag two.

When your preferred provider network address is wrong and GEHA refuses to fix it....Red flag three.

When your friends experience the EXACT same issue with GEHA in California and western Washington....Red flag four.

That GEHA had NO EXPLANATION other than go file an appeal with us and then laughed............Red flag five.

Where are you volunteering with USFS?? 

 

 

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Posted (edited)

Correct.

And if I appealed the decision with GEHA that is what they would probably do.  Drop it, as quickly as possible.

AND continue doing to the thousands of other Federal employees and their spouses that are retired.

NOT giving me an explanation and saying that I should appeal is probably another RED FLAG.  Really, if you can't explain to me and want me to file paper work with you leads me to suspect your really hoping I don't do it.

What I really don't understand is it for the "few" extra bucks they get to collect from Federal employees?? 

And then there is the issue of WHO BENEFITS from this policy??  The old follow the money argument.  I suspect there are several parties involved in this mess.

You know the old joke....you steal 51 million dollars from one person and your going to jail for a long, long time.  You steal $51 from a million people and nobody cares.

Edited by Vladimir
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Was your provider in or out of network?

Did the bill for the $51.00 come from the provider?

From the GEHA website.
Does GEHA pay out-of-network?

You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing).

 

Edited by pjstough
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Posted (edited)
3 hours ago, pjstough said:

Was your provider in or out of network?

Did the bill for the $51.00 come from the provider?

 

The provider was IN NETWORK. 

The bill came from the provider.

The Clinic has lots of facilities in a five county area.  The MAIN hospital and the MAIN Clinic are both in Wenatchee.

Looking at the GEHA site, my Dr. is in NETWORK, but they use the HOSPITAL address for her, instead of her office address at the clinic in Wenatchee. 

When I contacted GEHA they said that I didn't go to a preferred provider.  The address shown, on my billing for the physical exam was OUTSIDE the preferred provider network.  That is what got my attention.

However, for almost 20 years prior EVERY claim I have filed for the Clinic address was paid by GEHA.  Except this last one when they said the address listed is NOT a preferred provider.  NOTE....the address is not a preferred provider, not the Clinic providing the service.

That is why it feels like a scam.  Same medical provider...one address is a preferred provider the other is NOT.

Edited by Vladimir
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Unfortunately not paying insurance claims is a more common problem than many realize.  Before Medicare I received a bill for $18,000 for a surgery.  We had United Health Care and even though I was out of network they vastly underpaid.  Like Vladimir the local insurance commission couldn't help because it was a national employer provided policy.  I fought that for 18 months gaining a little help each time.  UHC assigned an advocate and she assured me my out of pocket should have been $2,000.  In the mean time the hospital wanted paid.  After 18 months my out of pocket was down to $4200.  Then the advocate quit and I was told I would need to start over with a new advocate. I gave up.  In the mean time with the first advocate we checked some of my DW bills and found UHC also shorted on her insurance.  Even when the shortage was identified we had to wait for UHC to send the claims through a committee and then management approval,  about 2 months before they would pay us what they owed.  I think insurance companies do that because "why not?"  One of the problems is the national law does not allow the local state insurance commissions to intervene with national provided coverage.  It was explained to me that because of that my choice was to work with the insurance company or hire an attorney and sue $$$.

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5 hours ago, Vladimir said:

The Doctor know there is going to be a problem with your medical claim.  Red flag one.

When your billing is miscoded?  Red flag two.

 

 

 

The issue overall from what I have read in the thread really seems to boil down to coding. In todays computer driven world coding is everything. One number or letter can make a huge difference in the amount billed or paid. In a perfect world the doctor codes what they have done and then the person that submits the claim reviews what the doctor has coded and then lets it go on or kicks it back. Now something I learned from having a spouse that did that type of work and a brother-in-law that is CEO of a hospital it comes up fairly often in conversations. The codes undergo major dates annually and minor updates quarterly. It can be a lot of info to retain and doctors are only human along with their staff. 

While I do not have GEHA I do have Tricare for Life as a military retiree and one thing I have learned (with some heartburn involved) is that things that might have been covered under Tricare Prime are no longer covered under TFL. I would suggest that this is possible in your case. Somewhere in all the fine print that the government is so fond of might be something that says it must be covered by Medicare before GEHA will cover it which is how it works with TFL. I'm not saying this is it, only suggesting the possibility. 

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5 hours ago, Vladimir said:

When somebody makes a mistake it is usually limited to ONE person and ONE item.  Mistakes are fine, everybody makes them.

However when........

The Doctor know there is going to be a problem with your medical claim.  Red flag one.

When your billing is miscoded?  Red flag two.

When your preferred provider network address is wrong and GEHA refuses to fix it....Red flag three.

When your friends experience the EXACT same issue with GEHA in California and western Washington....Red flag four.

That GEHA had NO EXPLANATION other than go file an appeal with us and then laughed............Red flag five.

I really wish I could say I was surprised but I am not.  As I said I an nowhere near as happy with GEHA as I used to be. Even the GEHA dental. In all my time with the government I have been covered by GEHA. One year with Kiaser Permanete, 2 years blue cross the rest GeHA even into disability retirement then regular retirement..  The more you say the more I believe that is multiple incompetence for maybe different reasons from each one. Which GEHA option do you use? I am almost dead sure under the high option I have I don't have to use the preferred network if you have medicare.

I am at the Sandia Ranger Dist. of the Cibola NF by Albuquerque.  Been here every summer except 2 since 1997. Never completely wintered here but came close during the pandemic.

 

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If I were in this situation, I would go back to the provider and tell them that they used the wrong address in filing your claim, and that they should refile or correct the claim using the correct address. Then the provider would accept the $353.00 as paid in full or GEHA would then pay the extra $51.00.
In my view, if anyone is scamming you it is the provider by using an incorrect address when they filed the claim with your insurance.

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BUT, GEHA REFUSED to change the billing address when I pointed out that it was incorrect.  Remember GEHA told ME that the address was incorrect.

Also GEHA has pulled the same scam in California and western Washington.

I suspect this involves BOTH the provider and GEHA.

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