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Linda
Brandwin, R.N.
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Linda
Brandwin
is a registered nurse and a medical billing
and claims specialist. For the past 10 years
she has worked directly with insurance companies
to give advice and guidance to the health care
consumer.
Readers may send email
or write Linda Brandwin at 5500 Single Oak Hill
Ct., Woodbridge, VA 22192.
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Medicare
reimbursements are baffling
June 25, 2004
Q:
I
am baffled about a Medicare response regarding a trip
to the emergency room when my husband had a nosebleed.
He was billed for control of nosebleed; code 30903 for
which the charge was $251.00. Medicare approved $74.14,
or about 30%.
The
emergency treatment did not stop the bleeding so an
ENT surgeon saw my husband. She had to leave her office,
come to the emergency room, and cancel some of her appointments
in order to attend to my husband. My husband lost a
lot of blood, and the doctor admitted him to the hospital
for four days.
The
ENT surgeon's billing for control of the nosebleed,
30905, was $437.00 of which Medicare approved $98.70
or about 23%.
These
percentage cuts seem disparate given the level of service
provided. Fortunately, we have been healthy and not
had to deal with medical bills. However a cut that deep
seems unreasonable. Thanks for any input.
A:
You
are not the only person who is baffled by Medicare.
You just have to remember that the bottom line is money.
When
Medicare first began, there was no such thing as approved
amounts or disallows. The healthcare providers would
submit their fees, and Medicare would pay. Actually,
there was no such thing as healthcare providers either.
They used to be called physicians. Anyway, one day the
government decided they could save lots of money by
regulating what the healthcare providers can collect
for each procedure performed. Thus, markdown medicine
began. Then the private insurance companies saw how
successful Medicare was at saving money by cutting their
reimbursements to the healthcare providers, so they
followed suit.
This
was the beginning of procedure codes, diagnosis codes,
referrals, co-pays, participating providers, HMOs, PPOs,
EOBs, and the list goes on and on. Today we call this
evolving process Healthcare Reform.
So
in answer to your question, Medicare's approved fees
for your husband's care are correct. The fairness of
the reimbursements is bafflingly questionable.
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