Linda Brandwin, R.N. 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.

Call insurance company to determine primary and secondary care
Dec. 17, 2004

Q: I am now 65 years old and I have Medicare Part A and B and AARP Medigap. I have no problems with any of these.

Eleven years ago I took early retirement with extra incentives. Additional benefits included medical insurance until I was 65.

Unluckily, eight years ago I became ill. Later that year I was awarded disability. Two years after that Social Security sent me a Medicare card for Part A and offered me Part B for a fee of $48 per month. Naturally, since I had the health insurance sponsored by my company which costs me $60 per month and has full prescription benefits, I chose not to pay for Medicare Part B.

From the time that I received this Medicare card for Part A until I turned 65, all of my health care providers' charges, including hospital charges, have been paid except for one bill. It was for my cardiology consultation which cost $458.

Now the cardiologist's office, the health insurance company, and I are bouncing this problem back and forth like a volley ball for the last three years. The health insurance company now says that since I never took out Medicare Part B they are not responsible for the bill. It floored me to hear their scam.

I have had two hospitalizations that I know both Mediare A and this insurance company paid on. There were no previous coverage problems. Why does this insurance company refuse to pay this obligation? They have received my $60 payments every month along with my company's contribution.

A: I can not tell you the exact reason why this insurance company is refusing to pay your cardiologist's bill, but I can make a good guess. Oftentimes there can be confusion over primary and secondary coverage especially when Medicare is involved. You started out with this insurance company as your primary coverage. Then you received Medicare Part A because of your disability. At this point, Medicare could either be acting as your primary carrier or secondary carrier. The fact that you did not have Part B which covers the doctors' fee just confuses the issue.

I have actually had similar situations where I have called both the insurance company and Medicare to find out who the primary is and who the secondary carrier is. They have both insisted the "other one" was the primary insurance carrier. This has happened numerous times. Somehow and somewhere at the beginning of this claim's process, I believe there was a misinterpretation of your benefits that generated this problem and has since ballooned without a resolution.

If you do not know if Medicare was your primary or secondary insurance at the time in question, call Medicare and find out. Even though you did not have Part B, you still need the clarification.

Now call the insurance company's claims' supervisor. The question here is whether this company was your primary or secondary carrier. The company was your primary insurer before you had Medicare Part A. Your status never changed as far as physicians' bills. They used to pay them, why did they stop? The only change in status was for hospitalization coverage. Why did their coverage for physicians' charges change? Your premiums stayed the same and no notification regarding benefit changes were received. You need and you are entitled to an explanation as to why they will not pay the cardiologist's bill. Let the insurance company know that you also want this explanation in writing so you can verify this lack of coverage in your policy and consult with a lawyer if necessary. It is your right to understand why this bill is not being paid. You pay your premiums; you are entitled to all benefits of your policy.