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Medicare Information for 2018 and beyond - USA Patients

Jamie

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Changes are scheduled for 2018 in the way Medicare provides coverage for surgical procedures including joint replacement surgery.

Currently surgery covered under Medicare provides a "bundled" payment for the entire procedure to the surgeon. The bundle includes visits by the surgeon while in the hospital, discharge, and post-op visits. For example, a knee replacement pays for 3 in-hospital visits, the discharge and 3 visits after surgery within the 90 day period from surgery forward (called the 90-day global period).

Beginning in 2018, the global period will change to zero (0), meaning that payments will not cover any post-op visits in the surgery payment package, essentially unbundling the payment process for Medicare patients. The reason for this change is the government auditors determined that the number of post operative visits to doctors was consistently below the three visits paid for in the bundling process.

So what might this mean for patients contemplating joint replacement surgery and the surgeons performing the procedures? For patients, there probably will be no direct impact as their needed post-op visits should be covered as an individual cost. But most certainly the surgeons will receive smaller payments for the surgery overall from Medicare. Assuming that 1 or 2 post-op visits are needed for an average case instead of the three now allowed under the bundled payment program, there will be less money going to your doctor.

It remains to be seen if this reduction in payments will impact how surgeons handle post-op care or if the reduction will impact the number of surgeons who perform joint replacement and other surgeries. So far there has not been much discussion of this issue, but as the deadline nears it should become more of a topic for discussion in the medical community.

Article link: http://orthobuzz.jbjs.org/2015/04/30/medicare-to-unbundle-postoperative-care-by-2018/?j=54677555&e=JAMIE@FARMORTHO.ORG&l=7404097_HTML&u=476059589&mid=186947&jb=0
 
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Jamie, do you happen to know anything about the case where Medicare acts as secondary coverage for in patient hospital stays?

My wife and I still have Regence UMP (PPO) as primary insurance, and we both have Medicare Part A. We've had this arrangement for about 3+ years or so and so far (thankfully) neither of us has been hospitalized. Our understanding from conversations with my wife's HR department and from Billing at a local hospital (after an emergency visit or two), is that Medicare will act as dual coverage, secondary to Regence, in the event of an "in patient" hospital stay (but not "out patient" like an ER visit), with the understanding that "in patient" means you were admitted to the hospital, and you spent at least 24 hours there.

My physical therapist also told me that he's seen a number of TKR patients younger and healthier than me requesting overnight stays for exactly this reason, where if you leave the same day, and it's considered "out patient", co-pays or co-insurance kicks in, costing potentially thousands of dollars.

I've been assuming this is the case, but I haven't confirmed it yet and was wondering if you've heard of this before. I do plan on verifying this with the Hospital when the time comes.
 
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Jamie

Jamie

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@robert johnson ... I have no idea and it would be unwise of me to try and guess! Your best bet is to check with the hospital and call Medicare to get the information straight from someone who knows the rules.

I do know that anything under 24 hours is considered "outpatient" for both private insurance and Medicare. There are copays for inpatient services just as for outpatient. If Medicare will act as a secondary policy (not really "dual" as they won't be paying the same as your primary coverage), they may then pick up the copay for you so you will have no out of pocket cost once you meet your annual deductible. These are all things to clarify with both carriers. It's the first of the calendar year and you may have deductibles to pay for both policies.
 
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OK, thanks. I just thought it might be something that was bantered around over the years. No problem, I will definitely check with both the Hospital and with Regence before the time comes.

You're right, I don't mean "dual" in the sense that they're both primary. One of them has to be the secondary, and we've been told it's Medicare, but only for "in-patient".
 

birdwatchr

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I will be having surgery April 1st, using Medicare part A as the secondary. I can let you know how they treat mine when the time comes. I’m scheduled for 3 days in the hospital, though, but was first told I’d be there overnight, then 2 days. (Don’t know who is more confused over how long I stay - doctor or me! lol)
 

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Had my rtkr 3 months ago and wanted to pass on some problems that I had with my supplementary insurance denying my surgery 1 day before it was scheduled. Called the insurance company numerous times to determine why it was denied and each time I was given a different answer. My surgeon luckily agreed to appeal my case to the insurance company. My appeal was approved, but only 2 days before scheduled surgery. Post-opperation my surgeon told me that he sees more insurance companies denying these surgeries. Unfortunately only 10 per cent of patients seek to appeal their surgeries. Make sure to find an orthopedic surgeon who would be willing to make appeals for patients. Final note, on one of my insurance calls to find why surgery was denied, it was that they thought it was experimental! My surgeon laughed.
 

birdwatchr

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Problem number 1: I was called by the hospital today, and they told me they could not take my Medicare card (part A only) until after surgery and the doctor deemed it necessary for me to be admitted because I was scheduled as “outpatient surgery”. I told them no I wasn’t, that dr said it could NOT be done as outpatient. They insisted, and said I could give them my Medicare info as they were taking me to my room once I was admitted. I asked “still under anesthesia I’m supposed to give you my Medicare info?” She had nothing to say to that. Then she said I had to call the dr about it, because she was told I was outpatient. Called dr’s surgery scheduler and she called hospital thinking she had made a mistake scheduling me. She hadn’t, but while I was on phone with her, I got two messages- one that cancelled my pre-op appt, and one that immediately rescheduled it. So I will try to give them my Medicare info when I go in for pre-op on Monday. Stay tuned.
 
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Jamie

Jamie

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@birdwatch4 .... how did this go for you? Are all the issues resolved with your insurance?
 

birdwatchr

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@Jamie have not yet heard anything from Medicare. The hospital is just now sending me notices, so I’m not sure regular insurance has covered it yet. So far it’s looking like I will owe nothing but my deductible, but I do have an out of pocket amount with company furnished insurance. Hope it doesn’t get tricky with Medicare!
 
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Jamie

Jamie

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It can be really tricky dealing with Medicare sometimes. Hang in there. I hope that all goes well with them once you're at the hospital. Did you ever talk to Medicare on the phone? It might be a good idea to call your primary insurance company too just to be sure things are in order.
 

birdwatchr

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Well, it’s been almost two months, and I’ve not heard a thing from Medicare. I don’t know if anything was even turned in to them. I did go online, but there is nothing to indicate they received a hospital bill. The only thing I could find was you only get a quarterly notification of your medical expenses. I will be off work for the summer next Friday, and hopefully will be able to call them and ask about it. I’m thinking that there was nothing they would have paid for after my primary insurance paid. So... no help after all to give anyone wondering.
 

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My doctor participates in a bundled Medicare program. My hip surgery was December 2018. They involve a Medicare nurse who tracks you in the hospital and at home to ensure you are getting everything you need at an adequate level so you are comfortable and happy with your care.
I saw my surgeon in the hospital, in 2 weeks, 6 weeks, 12 weeks and 6 months. I know there is another follow up at I think the 1 year mark where they take another set of x-rays.
Medicare is my primary and I have a secondary a lot of people don’t know about called IAC - Individual Assurance Company. They only medical insurance they offer is a Medicare secondary. I did pick a plan that wouldn’t leave me a huge out of pocket as another I had previously was supposed to be $3000 deductible but turned out to be $5000 before it kicked in fully. This one also has broader coverage and a deductible is less than a Costco shopping trip.
My care was seamless. I did see copies of what Medicare allowed and paid and it’s no wonder they bill so much...they get paid so little.
With a TKR next month, and the way this has worked so well, I won’t be making any insurance changes for 2020.
 

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@Jamie , in reading this thread, you got me nervous. My hubs, the Sainted Joe, had his left knee replaced Aug. 26th. Does the 24 hours run from time one checks in or time of surgery, if you know? They were in quite the hurry to discharge him the next morning - if he was there a full 24 hrs, I would be quite surprised. His nerve block hadn't even worn off. We have Medicare A & B with a Blue Shield supplemental. I can certainly understand them preferring to bill us for the hospital stay at a higher rate than Medicare would cover, but that is not why we pay through the nose for our Medicare coverage.
 
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Jamie

Jamie

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I'm sorry to cause you stress. The members I was talking with above had Medicare Part A (hospitalization only) as their secondary insurance, which is not the case with you. In your case with Medicare A & B, Medicare is your primary for hospital stays and doctor visits and will make the first payments on your account. Then Blue Cross, as your secondary insurance, should pick up any copays or other payments associated with the procedure. You should not have any work to do to get these bills paid and you should receive copies of the the transactions to see what each paid out.

I don't know the particulars of billing processes in every case. But it is my understanding that Outpatient procedures (which is what 24 hours or less in a hospital would be considered) are billed differently (different coding) than if you were in the hospital for more than 24 hours. I don't think you need to worry about Medicare and your secondary insurance covering everything, it's just that the billing process may be different for all the providers involved. With Medicare and a secondary, I would be surprised if you have any payments due.

The best thing to do is to contact your surgeon's billing office and ask them how the process will work. I'm pretty sure you'll be reassured that everything will be fine.
 

NightQuilter

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Thanks for the prompt reply Jamie!! I shall sleep better tonight! :spin: Joe is 3 weeks tomorrow, has had an amazing recovery (except for when he didn't pay attention to me and went cold turkey off his meds at 9 days!:bignono:). Minimal swelling, only a tiny bit of bruising by the heel, and already at 120/5!! Made me jealous! His OS on Friday said "sometimes we get it right! :rotfl:
 
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Jamie

Jamie

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Cold turkey off meds???? Oh my. Of course you didn't tell him, "I told you so".....:heehee:. Bet he won't try that again. Glad to hear his recovery is going well. The surgeon is right, though....it's the luck of the draw sometimes. I'm also glad I could reduce your stress level a bit tonight. It still would be a good idea to do some calling in the next few days just to be sure everything is in order.
 

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I was SOOOOO tempted, but it would have been lost in the throes of his sweats and nausea, and depression! And even though he went through it with me between my knees (surgery date wise), he didn't listen when I suggested the BoneSmart way of weaning off. Men!! :flabber: Got his attention though when his in-house PT person said "at your age that could have caused a heart attack!"
 
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Jamie

Jamie

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Whoa! That comment by the therapist is an eye-opener. I frankly never thought of that, but it makes sense. I'm glad he was okay. I did the same with hydrocodone on my first TKR and had three days of pure misery - like a bad case of the flu (fortunately no depression). I certainly don't recommend it to anyone as a way to stop prescription pain meds.
 

birdwatchr

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I must have forgotten about the Medicare part a question- so sorry. I’ve had 2 surgeries and one hospitalization since April and the part a is the secondary since I have insurance through my work. Medicare paid nothing! They did not take care of any extras, etc, which I kind of figured they wouldn’t, but was hopeful. So, in answer to the original question I answered, Medicare will pay nothing towards the hospitalization if you have primary insurance through your work. Most likely because your primary insurance pays more than Medicare would have in the first place. Hope this is helpful to someone.
 

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