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Helene Pavlov, M.D.

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How Does Medicare Really Work?

Posted: 07/18/11 04:39 PM ET

In addition to being a health care provider, I am also a patient, and the wife and mother of "patients." As a health care provider, one would think I would know how to navigate the insurance aspects of patient bills. These past 18 months have been eye-opening and worth sharing. I thought I was insulated from insurance issues since I have access to the right people, those with the knowledge and contacts to work through misinformation, automated systems, incompetent customer service employees, and health care insurance provider apathy. I was wrong.

Where to begin. More than a year ago, my husband became eligible for Medicare. This seemed a wonderful benefit. At the time my husband became eligible for Medicare Part B he had lifetime family coverage from his prior employment for the City of New York and I was carrying family coverage through my work at the Hospital. As an attorney and someone who needs to know everything about everything, my husband researched Medicare Part B with the Social Security office in New York City. We went together and answered every question they asked and they did the same with our questions. They could not have been more pleasant, informative and helpful. We were informed by our contact at Social Security, by his benefits person for the NYC health care insurance and by my health care customer service representative -- 'Medicare Part B is always primary.' Everyone had the same mantra. My husband signed for his Social Security benefits to be reduced in order to cover the Medicare premiums. He received his Medicare Part B card.

Being fiducially wise, my husband specifically waited to make doctor's appointments until he had this coverage in place. All seemed well for about a month. Then we started noticing problems and confusion with payments from Medicare. It was inconsistent, some doctors got paid, and others did not. We called Medicare Part B, received apologies and "not to worry" comments. Bills that were not being resolved were submitted to his and/or my insurance companies according to the information we were given by Medicare and by each of the insurance companies with which we had coverage. Basically the information they each provided us was simple -- the "other" insurance company was responsible, regardless of which insurance company we spoke with.

As frustration continued, I reached out for help and coordination of benefits. It seems that since I work at a company with over 20 employees, my insurance coverage is primary for my spouse, and then comes his insurance, then Medicare Part B. Well, as definite as that statement might be, this was the first time we were provided with that information despite multiple discussions with both of our insurance companies and with Medicare. With that information validated, my husband felt the monthly premium for Medicare Part B was unnecessary, and he dropped it. Bills seemed to stabilize.

Then, about 16 months later, Medicare contacted him by mail asking for reimbursement of any money paid to us and/or to the providers for physician's visits/service that they paid for during the two months that he was a participant in Medicare Part B. The letter states that should the money not be returned, Medicare Part B will garnish his Social Security check. The letter also indicated that there is "no appeal process" until the money is returned. Curious, there was no mention in the letter that Medicare would be returning the money it received as premiums for providing coverage during this time period that they claim no responsibility.

Some of the providers who received Medicare Part B payments were contacted directly by Medicare and were asked to return the money and call our other insurance companies, but when they reached out to our insurance companies they were informed that my husband was not covered during that time period. This was particularly distressing as we both have carried continuous family coverage for the past 28 years.

To resolve these issues, I have been trying for two months to speak with a live individual at my insurance company but until recently succeeded only in leaving messages on an automated system to my "dedicated benefits coordinator advisor." Even when I reached a live person I was almost instantly put through to an automated system, despite my pleadings. Return calls to explain the situation did not occur.

I suppose if one is retired and is looking for something to do, this healthcare insurance morass could be said to be responsible for keeping your mind activated and blood pressure elevated. "Coordinator of Benefits" seems to be an elusive job title that is on the books of every insurance company but exists only as an automated telephone service with recording functionality.

As I see it, my husband had coverage by three health care insurance companies between February to April a year ago. Although they all received and cashed their premium, each one claims not to be the primary provider for coverage. In order to keep our providers happy and the patient-physician relationship intact, it seems that the patient needs to pay for the care they receive as well as pay for insurance. Not sure exactly what health insurance coverage truly means.

More needs to be done. Patients should not be put through this. I cannot help but think that the insurance companies, like AIG, believe they are "too big to fail" and patients are like the small banks, disposable. Who is wrong and who is wronged by these processes and by this thinking? Something is not right. Most recently, I was finally able to speak with a live person at my insurance company and was told to send all the correspondences we were receiving from Medicare. He seems very responsive. I am hopeful, perhaps naïve.

HSS