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

[Barbaraok]

Why have you not contacted Senator Murray's office?  Or Senator Cantwell's?   Both of those senators really do work for people in Washington State.  Federal agencies tend to respond rather quickly when a Senator's office makes an inquiry.   Send all of the documentation you have along with the narrative you've put together here, to both of their offices and let them know that you are sure you aren't the only one in the state who is getting gouged by the agency.   

[Vladimir]

Thanks everybody for the questions.  I am still looking for others that have faced the same issue.

It did help to clarify and organize my thoughts.

[bigjim]

I hope you get to the bottom of it and post an update on occaision as you go.  In your case I am not yet convinced it is a plot but I would not be surprised either.  I am still convinced the constant onslaught about "Medicare Advantage" (part c)  is a plot to kill medicare. i will be watchful over my dealings with GEHA.  Good luck.

[Vladimir]

Thanks....I will post updates.

There is a chance that I am WRONG.  In my 72 years, it has happened maybe once or twice??

BUT so far, NOBODY (GEHA, etc.) have explained to me WHY I am wrong.  The comment is if you don't like it...file a formal APPEAL WITH US and we will decide.  

Right...that seems really productive use of my time.  I would rather call a cop first.

It is the equivalent of somebody stealing stuff out of my house, calling the cops and having them say.....well, talk to the thieves and see if they will give YOUR STUFF back to YOU!!!

I do KNOW that I will have a new insurance carrier this fall and it will NOT be GEHA.

 

[pjstough]

1 hour ago, Vladimir said:

Thanks....I will post updates.

There is a chance that I am WRONG.  In my 72 years, it has happened maybe once or twice??

BUT so far, NOBODY (GEHA, etc.) have explained to me WHY I am wrong.  The comment is if you don't like it...file a formal APPEAL WITH US and we will decide.  

Right...that seems really productive use of my time.  I would rather call a cop first.

It is the equivalent of somebody stealing stuff out of my house, calling the cops and having them say.....well, talk to the thieves and see if they will give YOUR STUFF back to YOU!!!

I do KNOW that I will have a new insurance carrier this fall and it will NOT be GEHA.

 

Again, from what you have posted the problem is with the provider not using the correct address when filing the claim, and GEHA can not arbitrarily change the address on the claim from the provider. Contact the provider and tell them they used the wrong address on the claim and resubmit, or update the claim. If anyone is pulling as fast one, I believe it is the provider. It seems to me that the provider has agreed to accept an allowed amount for a physical when in network, which was the $353.00 that GEHA would pay, however, if a provider is out of network then the provider can charge more than the $353.00, and is why the charge was $404.00, and the provider wants you to pay the extra $51.00.

[Vladimir]

On 4/30/2022 at 7:04 PM, bigjim said:

I hope you get to the bottom of it and post an update on occaision as you go. ............ Good luck.

Here is the update as of December 1st.

I paid the $51 with the Clinic, after I told them the Attorney General of the state of Washington was willing to take my case.  I would pay the $51, but expected restitution when the case settled.

I found the Health Fraud Line for Federal employees to report health care fraud.  I called the 800 number and was interviewed by para-legal for about a half hour.  She then sent her report to the Inspector Generals office where it was reviewed by a government lawyer. 

I got a TWO page letter saying go ahead and file the appeal with GEHA and see what they do with it.  Then call us again.  Right, I really don't care of the $51, but I am looking at somebody committing systematic fraud on the taxpayers and you refuse to even look into the issue further!!!

At this point we are looking at mid-August, so I decided to go through the physical routine again.

Just got my bill for my physical.  The cost to me is ZERO.  The address used was that for the hospital which is in network for GEHA, unlike the clinic address which is out of network for GEHA.

It does show that the amount billed was $251 for the doctor and the amount allowed was $174.  But my responsibility is ZERO.

The procedure code is NOT listed a physical, but instead as medical services.  THIS Explanation of benefits actually had the explanation codes.  They were not clear, but better than nothing.

So the story is paused.  I got the health benefits that I and the taxpayers pay for myself. 

Don't know what happened.  Don't know who fixed it.

But I am still curious are other retired Federal employees still being billed for the physical exams??

Edited December 6, 2022 by Vladimir

[Vladimir]

Update 2. 

Just got my new insurance cards in the mail today.  And the insurer in the letter mentioned the No Surprises Act which was passed by Congress in 2020 and went into effect 2022.  

It all starts to make sense, when you read the following information from the Federal government on the No Surprises Act.  I can see why GEHA had a non-prefered provider billing address and a prefered provider billing address for the SAME provider.

I suspect that the changes are all due to the No Surprises Act.  Just reading the following it seems that the split between prefered provider and non-prefered provider was a significant money source for the insurance companies.

The key point is that the facility now has to tell you upfront which service is outside the preferred network.  Which is my case, would have caused an uproar on the FRONT end and a loss of business for the clinic. 

Again, I suspect my claims had nothing to do with the change in my coverage, but the No Surprises Act given its emphasis on non-preferred provider billing probably did.

Anyway here is some text from the government on the Act.

What are surprise medical bills?

Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.

What are the new protections if I have health insurance?

If you get health coverage through your employer, a Health Insurance Marketplace®,[1] or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).

Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.

Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.

Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

 

Edited December 8, 2022 by Vladimir