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Thursday, November 4

The Medicare Nightmare: Reflection of a Member’s Experience with Medicare Billing

Michele Makinen, LCSW

This is the story of how my eighty-two-year-old counseling client unwittingly ended up with an outpatient healthcare plan which is completely administered by an insurance company and which requires pre-authorization for mental health services, a managed care-like review following 10 sessions and a co-payment of $45 per session.

My client has Medicare and a supplemental insurance policy from Secure Horizons of AARP—or so I thought. As usual, I sent my billing statements to Medicare, with the expectation that they would pay the allowed amount and send the billing to insurance for further payment as a “crossover claim.” When Medicare denied my claim, I found out that the denial was because My client no longer has regular Medicare administered by the U.S. Government, but instead has one of over 700 insurance products signed into law by former President George W. Bush, called “Medicare Advantage” plans. These plans wholly substitute for Medicare and are administered in total by the insurance company. In my client's case, it is a policy called “AARP Medicare Complete Secure Horizons,” otherwise known as an insurance product of United Healthcare (UHC) and United Behavioral Health (UBH).

After spending about ninety minutes on the phone with Medicare and UHC, I discovered that pre-authorization was required for mental health services, with managed care-like review after ten sessions even though the policy has no limit on the number of sessions per year. I will be covered as an out-of-network provider as I am not a provider for United Healthcare, even though I am a provider for Medicare, which is irrelevant here. Also, the client has a co-payment of $45 per session. Neither my client nor I had any idea of these circumstances prior to starting therapy. Now I must resubmit my billing statements, for part of 2009 and 2010, to United Behavioral Health and Secure Horizons who may pay whatever Medicare allows. When they send the expected denial, I can then appeal the decision by sending a detailed letter to UBH explaining why I believe the claims should be covered. I don't hold out much hope for that. So now I must bill my client for the co-payment per session. Fortunately, this client can afford to pay the co-payment, but most clients would not be able to pay this.

What I Have Learned

  1. When people sign up with an insurance company for the Medicare Part D prescription coverage, often the coverage automatically slides over to Medicare Part B outpatient coverage, with this revealed only in the small print of the policy. Seniors can change their coverage only at the end of the calendar year.
  2. When a client has Medicare, I now know to check their coverage prior to providing therapy, in case pre-authorization is required and the person has one of the Medicare Advantage insurance plans instead of traditional Medicare.
  3. The large $45 client co-payment will be a shock to all clients and many clients will not be able to afford it.
  4. The large co-payment means that the insurance company may be paying what Medicare would traditionally pay, but it seems there is no actual insurance payment on a claim.

Helpful Phone Numbers
Medicare (for Illinois residents): 1-866-234-7340
United Healthcare: 1-888-867-5517
United Behavioral Health: 1-800-851-2054 or 1-800-559-5951

Posted on 11/04/10 at 09:04 AM

Comments

This story really resonates with me.  I came across it when looking for a UBH toll-free number for a woman on Secure Horizons who desperately needs counseling.  She is on SSDI and can’t afford to pay $40 weekly to get the help she needs to move forward with her life.  I encourage anyone who reads this to contact their Congressional representatives and let them know what a travesty these MA plans are, especially for people on disaibility.

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