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Hi all, have a question about Medicare. Just received a bill from a local hospital for some lab work my late MIL had in July 2017. They billed Medicare part A/B $345.58. Medicare paid $33.77. They made an adjustment of -$150.81 and are demanding payment of $170. This hospital is in network if that makes a difference. We also have not received a statement from Medicare stating MIL could expect to pay this bill. My question is, aren’t they only allowed to bill the patient a maximum of 20%? Isn’t $170 more than 20%? All this Medicare stuff is confusing, I don’t know if it’s 20% of the entire bill or what Medicare paid. I don’t think she had medigap insurance (I’ve seen no evidence of it and unfortunately her box of important paperwork was pilfered by her partner before it was given to us and her insurance paperwork wasn’t there). Do we need to pay the entire $170 or can we fight this? Thank you!

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Did you ever get this resolved?
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worriedinCali Dec 10, 2018
No. And we just got another bill from the hospital. They did send me a form she signed at the time she had the lab work done and it showed an out of pocket cost of $170 but I still think they are over charging because they acknowledge that Medicare approved $32.77 so they should only be charging her 20%. My husband hasn’t has a chance to deal with this yet. When it rains it pours, now his dad is having a health crisis! He was hospitalized from Wednesday-Sunday with what they first said was sepsis and pneumonia and then they said it was just malnutrition. He went to an Appt at the VA today and for light headed so they called an ambulance and that is the last I have heard. Mag have to start a new thread on that because my FIL is apparently not taking care of himself, he does have cancer and some unexplained health issues. Don’t think my BIL or his who who moved him out here to live with them are going to be willing to be caregivers.
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It sounds like an error which you could solve in 2 simple calls. Check with the Medicare policy to see if the hospital can actually bill extra, Then after their response call the hospital billing office.
I just completed something similar chasing after a $10 recurring lab bill for more than a year. The billing clerk solved it.
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JoAnn29 Nov 17, 2018
She did call the billing dept and they said Mom signed saying she would pay any difference. This is customary but meaning the balance after Medicare and supplimental pay. I told her the billing clerk is wrong. If a Medicare provider, they must except what Medicare pays. They received 33.77. Bal of 8.44 should have been submitted to supplimental, if not paid then Moms estate will pay the 8.44. I would love to know how they got the adjustment figure.

I have found that Medicare does not allow a lot for labs or xrays. I really don't know how these places stay in business.
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Thanks again. So that is why you are trying to figure out bills.

You know I had problem with a local Drs. billing clerk. Our insurance doesn't pay for doctor visits. Husband took daughter to Dr for what might have been a broken ankle and paid $40 for the visit. Later we got paperwork from BC saying they paid the dr $35 because it was an accident. When my daughter needed to go back I said something about a credit for $35. I was told it wasn't on my acct. Proved they were pd and and I was entitled to the 40 my husband paid. I was told no only the 35. After a month in going around and around I called BC. They called the Drs office and told them I was entitled to the 40 because they excepted thev35. I got a MO for 40 in the mail. Found out later that the billing clerk had been embezzling from the dr. Don't fool around with a former collector. 😊
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Thanks, so if that was all set up why did her partner go to probate. As you have explained, everything is in a Trust, no probate. Now, since there is a trust, who makes sure all debts are paid and house sold. Normally, if a Will, then the Executor or no will an Administrator. Just curious.

What does the partner think a lawyer is going to do for him. He must have known about the trust.
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worriedinCali Nov 16, 2018
My husband is executor of the Will/trust. MIL was trustee, he is her successor trustee/executor. He is the one handling all her bills and when MILs partner moves out of the house or dies the life estate ends and my husband will handle the sale of the house. We don’t know why he was calling probate and met with an attorney. My thought was that he was going to challenge the trust, particularly to obtain ownership of the house. This happened back in early June and it’s now November so IF he did meet with an attorney I think it’s safe to say the attorney told him he’s SOL OR that it would cost him an arm & leg in legal fees to challenge the trust. We would have heard something by now if he was doing something.
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I have no idea how a trust works so money doesn't go to probate. Can u explain. Who is trustee? Who are the beneficiaries? Just being curious.
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worriedinCali Nov 15, 2018
The beneficiaries of the trust are my MILs 3 children and her partners 2 children. I do not know enough to properly explain how probate is avoided but the trust was created specifically to avoid probate and this is stated in the trust itself. Avoiding probate is why most people create a trust. The only assets were a house-the deed was transferred to the trust, and her bank accounts however she was not advised to put her bank accounts in the name of the trust or designate it as beneficiary and since she had All 3 kids listed as POD beneficiaries they were able to withdraw the money. If her deferred comp and retirement count as assets then probate is not necessary because when she retired, she chose the option of taking a lower monthly payment so that the beneficiaries she designated could receive her retirement when she died. She did this officially through PERs and the deferred compensation plan. The house belongs to the trust so it doesn’t have to go through probate.
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Did u ask if supplimental was billed? If not they should be so give the billing department that info. When you receive the supplimentals statement see if they paid or not. I bet you the balance they pay or Mom owes is...8.34. You then send that statement with the bill to the billing department with the payment or nonpayment if supplimental pays. You tell the billing department that Medicare approved 42.21 for the service them receiving the 80% of $33. You are paying the difference of 8.44 the balance Medicare says you owe. (or not if supplimental picks up then u say that). You tell them you are not paying more than Medicare approved. If they have a problem with that, they need to contact Medicare.

There are some really lazy and misinformed billing clerks. I have a background in Accts Receivable and Collections. I hate to deal with one of the doctors offices connected to a hospital Mom was in. The billings I have received from them have been incorrect. If I didn't have background in posting payments I would have never figured out what I owed.
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Riverdale Nov 15, 2018
It appears to me from this post that there is not a secondary insurance policy. What isn't clear to me is that if the doctor is in network doesn't acceptance of payment from Medicare suffice?
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Cali - hmmmmm, just a thought but if BF mentioned probate knowing there was an already existing trust, I’d wonder IF, just IF, there’s assets that were not included in the trust. He’s been a bit of a snake in all this but knows what a Trust is, so why bring up opening probate?

There someone on this site whos folks had Trusts done & supposedly all done with a bow on it. Mom died first after a fall and hospitalization, then her dad about a yr later after he moved out of the house and into a lovely facility (he was happy there too)and yeah there were stocks dad left out of the trust. She had to open probate. I’ll PM you her screen name.
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worriedinCali Nov 15, 2018
I am pretty sure there are no other assets, my husband had conversations with his mother when the trust was created. She created the trust, everything is specified the way she told the lawyer to do it. If there is anything out there we don’t know about, it’s going to be life insurance policies! Her partner told us that they had multiple policies but cashed them in except for 1 policy. That 1 policy was one she had through her employer and she lost it when she retired (she didn’t choose to take over the monthly premium). Now 2 weeks after she died he also told all of us, all 3 kids and spouses, that there was a $20k policy they needed to collect on and that he had been paying $6 a month for it. But we can find no evidence of this policy existing. I think all the talk about life insurance was to deflect from the money he stole and get us to focus on finding the non-existent policy. I think he was trying to send us on a Wild goose chase and make us forget about the bank accounts for awhile. My MIL definitely did not own any stocks.
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I read the response about the rude man. He is wrong. Mom is not responsible because the doctor coded the lab work wrong. If billing is aware of this, they need to contact the doctors office and ask for a correct coding. Then they resubmit the paperwork to Medicare. You are not able to do this. Its their responsibility.

Signing a paper saying Mom would be responsible for any balance refers to the 8.44 if her suppliment doesn't pick it up or her deductable not satified. The lab has excepted the $33 (80%) they are entitled to 8,34 the 20%. That is all.

Since it seems like boyfriend has taken over, give him the bills. He needs to have a list of debts. He also should be figuring this all out. Give him my breakdown. If he took all the paperwork, then he may have the Medicare and supplimental paperwork. The supplimental will show the breakdown. What Medicare paid and what they paid or didn't pay. Always use the supplimental to determine what balances are left.

I just went thru something similar.
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worriedinCali Nov 15, 2018
Sorry for the confusion, MILs partner has not taken over! The first few days after MIL passed away, he was meddling and making phone calls on behalf of the trust when he shouldn’t have been doing that and one of the phone calls he placed was to probate. He was trying to keep in control probably to cover his tracks and keep us from finding out about the money he stole. My husband took care of that and told him to butt out. My husband is executor and is handling everything himself.

and thank you, I assumed the paper she signed was in reference to the same thing, not that she would be responsible for the rest of the original amount.
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Cali - yes & there’s likely to be others.
Remember it’s her debt not yours.
Is hubs opening probate? Or that boy friend of hers? Personally I’d kick this bill and any others that show up......and it can take years for the billing cycle to run its course..... to the ”unfortunately Jane Smith Jones, whose bill this is, died on xbxncnc and its anticipated that her heirs will be opening probate in the future. Your bill will need to file according to CA probate code as a debt against her estate. And remember - insert name of debtor here - there will be a NOC (Notice to creditors) in the newspaper of record for her probate court as to where that claim is to be filed”
Then hang up.

Really after the first couple of these, you’ll have this response down pat.
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worriedinCali Nov 15, 2018
Thank you. No there is no probate, she had a trust created when she went on hospice so we are able to skip probate. I do know that her boyfriend called probate within days after her death and made a comment the following week that he was seeing a lawyer—we don’t know anything about any of that and haven’t heard anything since. I don’t know if he can open probate since there is a trust.
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I would send death cert and let them go to all the trouble of billing her estate.

I think if you Google Medicare specialist you should find something.

I will PM u with the guy I used, maybe he knows someone in your area or can help.
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I hope the billing department can help you resolve this.
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When did she die? If it was longer than 6 months ago just send the rude man a copy of the death certificate.

I would look at her EOB, co-pays are such that you may or may not meet the deductible. It is a screwy system.

Can you contact a Medicare specialist insurance agent, they could look at the paperwork and help you understand.

Another avenue would be to file a Medicare fraud complaint, with your local office on aging helping you, that would get answers and resolutions.

I hope you can get this sorted out, I can feel your frustration. These scummy little vultures get off on making people crazy.
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worriedinCali Nov 15, 2018
Thank you, she passed on June 1, 2018. The lab work was done in June 2017, Medicare paid $33 on 7/3/17. I don’t have an explanation of benefits for this. We’ve received multiple EOBd since she passed and not one said she was responsible for any charges and I don’t recall one for hospital lab work, most were for her oxygen machines and hospice care . I also don’t understand why we are just now getting this bill if Medicare paid their portion in July 2017! The lady at Medicare said she could order something, she didn’t call it an EOB but I think that’s what it is and she said when we get it, we can call back to discuss MILs account. I’ll let my husband call and order that if he wants to fight this. We’ll send the hospital a copy of the death certificate, maybe they will write off the bill. If she owes it, the estate has no problem paying it but I really think they are being vultures & they are overcharging! And if she knew she had to pay, she would have paid them at the time of the services! She never wanted any outstanding debts, ever. She never let things go unpaid. I don’t know of any Medicare insurance agents here but will start looking!
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Update-lady at Medicare was very nice but couldn’t tell me anything since MIL did not have anyone authorized to call & discuss her account. All I wanted to know was if she is being overcharged. Medicare did NOT pay the 80% so I am back to square one, I don’t know if a Medicare patient can be billed the entire remainder of the bill.
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Just got off the phone with a rather rude man at the hospitals billing department. So the bill is for bloodwork and he said that the billing codes used by the dr are what caused my MIL be billed $170. He said she was informed at the time of services that she would have to pay and that she signed a form, he is supposed to send us a copy of that form. So to be clear, the doctor and the hospital is in network, the lab is in network and Medicare paid $33. Is it correct that the hospital can only bill her 20% and NOT the entire remainder of the bill? I have been on hold with Medicare for 20 minutes now. Their automated system is really something, i typed in my zip code and it wouldn’t recognize it and when I gave the last 4 of the social it kept saying I entered 0000!
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JoAnn, Thanks for the breakdown! My mom's clinic has been over billing her for years, and she's just now showing me and wants me to do something about it (LOL). I was so confused; you've made it much plainer, and that helps a lot! What doesn't help is the clinic was sold a year ago, and the new owner is a huge hospital group, who is doing the same thing, as far as I can see. The good news is my husband's mind works in these situations, even if mine doesn't (he used to be my bookkeeper at a Best Western I managed), so we'll sit down together and figure it out. If we end up having to go to war, that's where I come in...
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It is 20% after the deductible is met. Are you certain that the deductible was met in it entirety? It is like 4 grand and 184.00 for a different deductible. 2 deductibles and it is a bit confusing. I would think that the deductible was not met.

They can only charge what Medicare approved for the services.

If your MIL has died, send them a copy of the death certificate and that should be the end of it. I believe they only have 6 months after death to file a bill against her estate, after that they are out of luck.

If she ever had a supplemental insurance, you would have seen a bill or auto-withdrawal for premiums.

I would contact Medicare and ask them to help you understand how it works.
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worriedinCali Nov 14, 2018
Yes the deductible was definitely met—she had a lung biopsy in January 2017 and was in the ICU for 24hours afterwards following it and spent another 1 or 2 nights in a regular room. Definitely no supplemental insurance then-I’ve gone over bank statements going back 10 years, she never paid a health insurance premium.
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Joann29 the statement reads as follows:

laboratory charges $354.58
medicare O/P contr adj -$150.81
medicare A/B payment -$33.71
amount MIL owes. $170.00

that is the only information on the statement.

and again this was sent by the hospital. They have their own labs. This wasn’t an outside lab. And they take Medicare (aspire health plan). So when I call, it is correct they should have only billed 20% of $33.71?

also the lab services were actually 6/13/17. Medicare paid $33 in July 2017. I wish I could call and tell them they are 6 months too late and that if they want to get paid, they should bill their patients in a timely manner!
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If they tell you they are correct, call Medicare if doctor is contracted with them. Explain that doctor is billing you more than approved amount.

20% is not based on the amount charged but the approved amount by Medicare. I think someone in the billing department has made a mistake. If the estate has no money, the bill can't be paid. You r not personally responsible for it.
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rocketjcat Nov 14, 2018
The only thing I can think is the LAB they used is out of network. I ran into this a lot when mom was still on her Aetna plan. The doctors were in network , but the lab wasn’t. And the lab work was costly.
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Going to try and explain.

Normally if doctor accepts Medicare and your supplimental this is how it works.

Charge 345.58, Medicare approves 42.21, 80% is 33.77.
Difference between approved and 80% is 8.44 this is what ur supplimental should pick up. If the doctor is a Medicare doctor he cannot charge you more than the 8.44.

Trying to figure out how they got to 170. 00 due. This is how I got close.

Charged 345.58
Medicare 33.77-
_______
Total 311.81
150.81- adjustment
______
161.00
8.44 20%
_______
169.44 being billed.
Without seeing your paperwork this where I got. If he excepts Medicare the most he can charge you is the 8.44. He has to except the 33.77 because of his contract. If he feels Medicare has made an error he needs to resubmit. His office may have coded the billing wrong.

Like I said, without seeing your paperwork its hard but I think I have given you and idea how it should work.
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Thank you :)
yes her deductible was met in January of last year when she had a lung biopsy and had to stay at the hospital a few days. I plan to call the billing dept, I just hate to do it blindly without knowing how any of this works. The statement just says that Medicare a/b paid $33 and she owes $170.
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Call the billing department at the hospital and ask why the coinsurance is not 20%. Had she met her deductible already, or does this bill reflect the deductible amount as well as the bill?

The billing department is the place to start.
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