So, the nice lady at Medicare told you that it would be covered
Have you ever had one of those patients that just would not take, “I’m sorry that therapy is not covered by Medicare” for an answer? Have you ever had a patient like that who was also on the Board of Directors at your local hospital? Well, this week I received a call from an infusion company that was faced with that very scenario.
The patient was given the option of remaining in the hospital where all of his care would be covered by Medicare and his Medigap policy. Instead, he decided to go home to receive the six week IV penicillin therapy. Fortunately, the medication was reimbursed through part D and all of his nursing services were covered since he met the homebound requirement for Medicare part A. Unfortunately, the supplies and equipment associated with infusing the medication were not covered. Even a director of a hospital board could not understand the complexities of the Medicare program.
After the provider had properly billed Medicare and Medicare had properly denied the charges indicating that they were the patient’s responsibility, the patient decided to dispute Medicare’s decision not to cover all of it. Get this…after approximately 3 hours on the phone with a Medicare representative (imagine that) the patient was told that it appeared that the charges were incorrectly denied and that they should have been paid. Boy, if I had been on the phone with him that long, I would have told him anything to get him to hang up as well. The Medicare representative went on to say that the provider should resubmit the charges. We are talking about the intravenous administration of penicillin at home. How absurd is that? The provider plays by the rules and Medicare still wants to make their customer happy...give them false hope. More than likely the Medicare representative does not understand the complex coverage requirements either.
The provider recommended that the patient file a formal appeal in writing to Medicare rather than relying on the telephone representative’s opinion. The patient complied and within 4 weeks received a determination letter. As one would expect, Medicare’s response to the patient’s appeal resulted in no change in the original decision. Medicare formally stated that the charges had been submitted correctly and that they had been denied correctly. The statement went on to say that since the patient had been informed prior to therapy that Medicare would probably not cover the supplies and equipment, the patient would be responsible for payment of those charges.
The provider, having been placed in this position before, had expected the worst and hoped for the best. With a valid, properly completed, signed and dated ABN, I guess you could say that the provider won. After 6 months the patient did finally pay and now is an advocate for the new legislation for improved Medicare coverage of infusion therapies. Did it really need to take this long? Had a knowledgeable Medicare representative explained the correct coverage criteria, all of this could have been avoided. This should be a lesson to all of us…knowledge is power. Be prepared for the unexpected.