It’s getting serious now. My insurance just rejected my February dialysis bill for ~$33k. I still can’t get through to Medicare’s benefit coordination center; the wait time was too long last time so I need to try again tomorrow. However, I found a document on Medicare’s website that clearly states that I need to wait 3-months before beginning Medicare, and the 30-month benefits coordination starts after that date. That is why all the info I’ve received from my dialysis clinic mention the coordination period as 33-months. Now all I have to do is get my work insurance to agree and reprocess all the rejected claims.

I’m so frustrated with all this. I called our work insurance service provider again today and spoke to the claim supervisor. It turned out he has been out sick so he never got back to me. Anyway, their conclusion is that after 30-months of dialysis, Medicare becomes the primary insurance for all claims. Therefore, I need to have all my providers bill Medicare first, then any remaining amount will be paid by my work insurance. The problem is that Medicare starts three months after the first dialysis date of July 5, 2017, so by rejecting claims after January 5, 2020, my insurance is off by three months. The rules are so confusing that each time I call my insurance or Medicare, the answer seems to change. I’m now getting invoices for this failure of benefits coordination.

Because of this confusion, I’ve stopped seeing my therapist and acupuncturist. I also have several upcoming appointments to see the cardiologist, primary care physician, endocrinologist, and others. I feel like I need to postpone those appointments until the insurance situation is cleared up. My work insurance also started rejecting my cardiac rehab claims so I’m not sure how to continue there since the hospital doesn’t seem to want to bill Medicare on my behalf.

I called Medicare today with questions regarding coordination of benefits when I still have my work insurance. The person on the phone was really nice but the call took awhile since she had to look up a lot of info. I guess it’s not a common topic.

She confirmed that as long as I have my work insurance, Medicare will pay as secondary insurance, except for dialysis after 30 months, and the kidney transplant. I asked about previous claims where I paid a co-pay and was told that I can file a claim. However, if the provider charged more than the Medicare rate, and most do for private insurance, Medicare will calculate their responsibility with the lower rate. I’m still unclear what that means. If my doctors bills my insurance $200 and they paid $160 since my co-pay was $40, how much will Medicare reimburse me? If the Medicare rate is $100, will they pay up to $80 (80% of the initial claim at the lower rate), or pro-rate my co-pay and only reimburse me $20? We decided over the phone that I should just file the claim for $40 and see what happens. I also didn’t get any statements from my doctors so I’ll need to go back to all of them for more info in order to file the claims. Medicare does pay for cardiac rehab so that’s a lot of co-pay to get back for the entire program.

I also got the first statement from my dialysis clinic. The insurance amount was close to $30k. My work insurance only pays 85% but since I also have an out-of-pocket maximum each year, my portion comes out to ~$3,000. I’m thinking Medicare should pay that but their dialysis reimbursement rate is much lower, probably like $3,600. So will Medicare pay only 80% of that or $2,880? Also, if Medicare pays some of the bill, will my insurance count that when calculating my out-of-pocket maximum? Otherwise I’ve hit my max and my work insurance will pay 100% from now on. Super confusing.

Crap! There were five claims (so far) that my work health insurance screwed up. When I called them, I thought there was only one but after going through all the claim activity online, there were four more where my work plan paid as if they were the secondary insurance. I sent them a secure message on their platform with all five claim statements. I hope they review and repay in a timely manner so I don’t have to answer all sorts of calls from my doctors. Sigh…

I still have to call Medicare to figure out what to do with all my co-pays. I figure I must have paid >$350 in co-pays excluding acupuncture and therapy. Not sure if those two things are covered. I called Medicare once before and they were pretty helpful so maybe this won’t hurt too much.

I talked to our benefits department and they found an 85-page plan detail document from 2017 that clearly states if I qualified for Medicare because of ESRD, our insurance plan would be primary and Medicare would be secondary. This is contrary to the last claim details I received. Our benefits coordinator requested a callback from a supervisor from our insurance and he verified that our plan should be primary. He also said he would ask his team to reprocess my claims again to make sure they were paid out correctly. Yay! I was afraid I had to mediate between insurance plans if both thought they were secondary insurance.

Like my sister, our benefits coordinator said this coordination of benefits when you have multiple insurance coverage is the most complicated topic in health insurance. No one wants to be the primary coverage insurance since they usually paid 80%-85% of the claim. I avoided getting Medicare because of this coordination mess, and only got it because my work insurance will stop paying for dialysis soon.

The fun starts now! Back on January 10th, I went to see a podiatrist for a check up since I’m diabetic and have peripheral neuropathy. Since the podiatrist was a specialist, I paid my $40 co-pay and thought everything was fine. Well, the podiatrist office finally filed the insurance claim, and I got the following statement of benefit from my work insurance.

The podiatrist office billed $274.00 for my visit but the negotiated rate for Blue Shield is $194.53. My insurance then determined that since I have Medicare starting 1/1/2020, they are the primary insurance, and should cover 80% or $155.62. Therefore, my work insurance only needs to cover the remaining 20% or $38.91. On my call with my work insurance yesterday, they said I need to give all my providers a copy of my Medicare card so they can bill Medicare. For this claim, I should get my $40 back once Medicare pays. I had a lot of doctor appointments in January. Since none of the claims have been processed, I will need to do this with 5-6 providers and lots of claims.

I see some potential problems with this. First, once I pay my co-pay, it’s very hard to get that money back. I have to follow up on each claim to see if and how much Medicare pays, and harass the doctor’s office for refund. Also, who determines which insurance is primary? What if Medicare decides they are secondary and my work insurance should pay 85% first? Also, for the claim above, the plan rate was less than what the podiatrist billed. What is the Medicare plan rate? I think it’s often less than private insurance reimbursement rate. So what if Medicare’s rate is only $100 and they pay 80% or $80? What happens then? What if the medical provider does not accept Medicare in the first place? Sometimes I think having a single health insurance payer, like they do in Canada, is much easier on the consumer. Doctors and hospitals will probably lose out though since reimbursement rates will definitely be lower.