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John R. was admitted to the
hospital through the emergency room. He never
had a chance to meet with the people in the
admission office. Flo, his wife, was with him
every step of the way, and she never left his
side to go down to Admissions, either. When he
checked into the emergency room, Flo showed the
clerk John's Medicare card, but she forgot all
about the card from his secondary insurer.
John was in the hospital for almost three weeks.
He had a lot of expensive tests, and then
surgery. It was not an inexpensive stay.
Happily, he went home in better shape than he
went in, and he has recovered well.
His pocketbook hasn't recovered quite so well,
however.
Soon after John returned home
the statements from Medicare began to arrive.
Each one said in big black letters across the
top, "This Is Not A Bill." So John and Flo filed
them away.
Then, about two months later, they began to
receive bills from the hospital. And then bills
started flowing in from a multitude of doctors,
some of whom they had never heard of. Each bill
was for several hundreds or even thousands of
dollars. Again, John and Flo weren't worried,
because their secondary MediGap insurance was
supposed to cover everything Medicare didn't.
The bills turned into
statements, each more urgent than the last. John
and Flo thought their MediGap insurer was a
little slow, but that all these bills would
eventually be covered.
Months passed, and the couple began to get nasty
calls from bill collectors. John and Flo aren't
stupid people, but they are uneducated about how
hospitals and Medicare work. Early on they made
the logical assumption that everyone in the
system communicates with everyone else. Sadly,
logic doesn't prevail in the world of medical
insurance.
Medicare does not automatically pass along bills
from medical providers to secondary insurance
companies. If the hospital or other provider
doesn't know about a secondary insurance policy,
they will not be able to send the secondary
insurer a bill for the balance not paid by
Medicare. That balance is instead billed
directly to the patient.
That's what happened to John and Flo. Eight
months or so into this saga John and Flo were
frightened enough by all the bills and telephone
calls that they gave in and paid the outstanding
balances. They refinanced their home to do this,
so now they have higher mortgage payments, no
home equity, and little left in the way of
savings.
Bitter about the "useless" secondary policy they
bought, they switched from their traditional
Medicare policies to Advantage managed care
policies.
Had they understood how the system works, they
would have contacted the hospital. They would
have given the hospital John's MediGap policy
information. The hospital would have then billed
the secondary insurer for everything not covered
by Medicare. If something is covered by
Medicare, then the secondary policy must cover
the insured portion.
Unfortunately, John and Flo never called the
hospital or their MediGap insurer, and they
never asked for help with their problem. They
didn't know that the fault didn't lie with their
MediGap insurance, who never knew about any of
this. By the time the real problem came to
light, they had made their financial mistakes,
and too much time had elapsed for them to make a
secondary insurance claim. All insurers have
deadlines built in to their claims mechanisms.
Wait too long to file a claim and it will be
denied as "not timely." Six months appears to be
a common cut-off.
So now, two years later, it's much too late to
do anything to help John and Flo.
The important thing to learn from this is that
making the assumption that anyone communicates
with anyone is a big mistake. If you or someone
you care about is receiving medical care, take
it upon yourself to make sure that every
provider has complete information about all
insurance. Keep photocopies of the front and
back of all the cards, and pass these copies out
like candy.
If bills or statements come in and you see no
evidence that a secondary insurer was billed,
immediately request that this be done. One
telephone request is fine. After that, if you
don't see progress, make your communication in
writing so you have a paper trail. You can make
yourself a form letter to reduce your workload.
Once you have started your paper trail, the
clock is also ticking for the medical provider.
If the provider does not bill the insurance
company, they may well be held responsible for
the amount not billed. They may not be permitted
to bill the patient for unpaid balances if they
have not billed the insurance company in a
"timely" manner after receiving complete and
timely insurance information.
This is all very confusing for an elderly person
who may not be in the best of health. Taking
over responsibility for tracking the medical
bills and insurance payments is one way you can
be extremely helpful, even from a distance. Even
if you are confident that your elder is able to
manage the bills and paperwork, you might ask
how things are going. Sometimes simple lack of
knowledge can derail even the most competent of
us if we don't know that we're missing critical
information.
If you'd like more information
about Medicare supplement policies you can
download and study Medicare's pdf book on the
subject:
Choosing A Medigap Policy: A Guide To Health
Insurance For People With Medicare 2007
Right click on this link, then save the pdf to
your desktop or another place on your machine
where you will be able to find it.
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