FYI Medicare and CCSVI

[mickb]

Hi All:

I just received word from The Vascular Group, PLLC in Albany NY that Medicare will not be covering any services related to ccsvi.

I was told the initial cost of the office visit and ultrasound is $318.50 and they require a $10,000 deposit at the time of the venogram. Not sure what the full cost of the venogram is?

I had dopplers of my Juglars done Buffalo (part of a study) and they said they were clear. I'm very suspicious of the azy however.

My appointment in Albany was Jan 4th but I'm thinking this might be a deal breaker. Ouch.

Has anyone else heard this?

Mick

[nellie]

I've not heard this before. Has anyone experienced Medicare denying coverage of this?

[HappyPoet]

Ouch is right. It seems like the sleeping giant is starting to wake up to what's been happening.

In August, Medicare paid (its usual 80%) for my two procedures with Dr. Mehta. In fact, the payment sailed right through without a hitch which is why my private health insurance picked up the remaining cost (20%).

For those without insurance or who do not want to pay out-of-pocket, there are CCSVI randomized clinical trials, but I'm confused as to whether or not the patient has to pay for the venography but not the venogram or if there is no cost at all to the patient.

Best of luck!

[Cece]

Could it be that the Vascular Group doesn't want to take the risk with submitting to Medicare? There have been other facilities (Arizona, CCSVI Imaging in Atlanta) that didn't accept insurance at all. Not because insurance didn't cover it, but because it is a risk for the provider. By the time things are submitted to insurance and come back denied, the provider has typically performed many more procedures that may also be denied and rung up costs that may end up never being compensated.

But if Medicare and insurance stop paying for CCSVI treatments, I will cry!! For myself and for all of us.

[CCSVIhusband]

My bet is exactly what you said initially Cece.

A LOT of doctors don't deal with medicare because they get shafted by the US government when it comes time to pay. My guess is that's what is happening here.

Insurance on the other hand (private insurance) is a more safe bet that you'll get paid, because it gets cleared prior to things happening. Venous issues are a known thing, and covered under US insurance (Joan/Cheer has posted about it before ... I'm not going to dig it up).

But Medicare and the government behind it, a lot of doctors choose not to deal with ... why do you think that healthcare debate was so divisive last winter? (we're going to start seeing more and more of this kind of stuff with the government dipping its toes in that water).

[mickb]

Thanks for the reply's everyone!

I probably should have mentioned that I was planning to switch to medicare to avoid the delays in my hmo pre-approval cycle. I'm about 7 hr away by car and was hoping to complete things in a week. I don't travel very well these days.

I understood (from a person at The Vascular Group) that they accepted medicare and things were ok. I admit that was a few months ago and things change.

It seems very bad that they would lie to me.

Here is the exact quote

"Morning Mike

We have just received word from Medicare that they will not be covering any services related to ccsvi so I’m not sure how you would want to proceed at this time, the initial cost of the office visit and ultrasound is $318.50 and we would require a $10,000 deposit at the time of the venogram. Let me know what you decide and we can move forward from there."

It sure looks like they are talking about medicare and not the preference of the practice.

Yikes!

[newveins]

Medicare has never covered anything related to ccsvi as hello it is experimental. It has always been about how the claim was filed. A covered claim might have looked like it was covering ccsvi but no Medicare simply cover what is covered. I should think a clinic that does mostly ccsvi or a lot of it would eventually be looked into if suddenly an epidemic of certain similar types of claims show up on their radar screen. I should think that would be the case eventually for all insurance companies.

One can argue with success sometimes with any insurance company including Medicare though that is a lot of work.

Do we really need to bring up the government here ccsvihusband you apparently just cannot help spewing negativity around and you don’t even have ms. I appreciate having medicare never had a problem with it and it is cheap and I have never experienced being denied care due to Medicare.

[Cece]

Insurance on the other hand (private insurance) is a more safe bet that you'll get paid, because it gets cleared prior to things happening. Venous issues are a known thing, and covered under US insurance (Joan/Cheer has posted about it before ... I'm not going to dig it up).

Thanks for the reminder, CCSVIhusband.

I know too that so many are paying for this fully out-of-pocket.

Has anyone else heard this from any other providers? Right now this is an isolated case.

[Donnchadh]

I have had two separate procedures and both were covered by Medicare-so I would be very much surprised if the government has reversed their coverage.

What I think is far more likely is that Albany doesn't want to take the "slice and diced" payment Medicare provides. When Siskin talked to me last summer, Medicare coverage was an issue to him. While he didn't say so, I suspect that was a factor in his refusal to treat me. He wanted to get pre-approval from Medicare which is something it never does, for anything.

Since I am hoping for another treatment under Medicare coverage, I sincerely hope this is not a change in government policy. In all the EOB (Explanation Of Benefits) paperwork received from Medicare, there was nothing about having this or that declined because it was a venous procedure. More that "we only pay pennies of their claimed expenses" for this or that-which I suspect is no different from any other procedure.

Donnchadh

[shye]

Mickb wrote:

just received word from The Vascular Group, PLLC in Albany NY that Medicare will not be covering any services related to ccsvi.

What about paying up front, and then getting the Vascual Group to submit forms to medicare for you--or at least fill them out for you to submit? First, check around for the codes used by others who have been re-imbursed by Medicare.
Seems they possibly worded their message to you incorrectly--maybe the group did not want to wait for payment, or did not want to take a lesser fee from medicare.

[mickb]

Hi shye

I wonder if that's it. They did ask for $10,000 deposit. I haven't found anything on the web about medicare policy change.

I was going to call Community Care and see if they could confirm - but then what do I do?

You have a very good idea. I'm new to medicare so submitting the forms myself didn't even occur to me as an option.

It's hard to believe that Medicare wouldn't pay to "unblock" a vein. I don't think there is a dx code for CCSVI anyway? What the nurse said in the email just doesn't make sense to me.

Thanks for the reply

Mick

[MS_HOPE]

Just a thought, mickb. I know that there are many doctors out there who don't accept Medicare patients in general (nothing to do with CCSVI), because they are either dissatisfied with the level of payment, or don't want the bureaucratic/red tape delays and hassle, or whatever.

I'd like to think that Dr. Mehta's office wouldn't have intentionally misled you. If they're not accepting Medicare patients, they should just say that.

Of course, it might affect how some of us might view their motives in treating MS, if they're not accepting Medicare patients.

Clarification from them is in order.

[Donnchadh]

Medicare payments are a growing problem; the CCSVI procedure isn't any different in that regard. There are reports of doctor's either declining Medicare entirely or strictly limiting the number of Medicare patients they are willing to see.

The problem, from the doctor's viewpoint, is that they have to "accept assignment" for their claims. A doctor could charge $1,500 to do a specific item (with its own medical claim code), and Medicare will determine that it's either not covered (usually for alleged duplication of some other service done the same time) or pay a small fraction. So Medicare in our hypothetical example might only pay $555.56 and there's not much the doctor can do about it.

If Albany doesn't want to accept Medicare patients, that's their prerogative, but they should be upfront about that.

Donnchadh

[bigfoot14]

Like donnchadh said. it's very likely they don't want to deal with medicare many Dr's don't want the hassle or the pay cut
when we moved we had to call 10 -15 GP's before we found one that would accept medicare and see my wife

[CureIous]

Insurance on the other hand (private insurance) is a more safe bet that you'll get paid, because it gets cleared prior to things happening. Venous issues are a known thing, and covered under US insurance (Joan/Cheer has posted about it before ... I'm not going to dig it up).

Thanks for the reminder, CCSVIhusband.

I know too that so many are paying for this fully out-of-pocket.

Has anyone else heard this from any other providers? Right now this is an isolated case.

Yes, but it gets ignored. There have been several that have been denied claims, though admittedly that is not the norm, right now.

Hopefully, someday, CCSVI will have it's own ICD code and this will become irrelevant, but for now, it remains the oft-quoted codes we all know about and hopefully stays that way for MS patients. We haven't really seen full effect of any of this in the US, it's not national newsworthy (as deemed by whoever makes such political decisions for the networks), and as such, is a relative unknown in the populace in general. Whatever media>public>insurer cycles we've seen in Canada, will be starting anew as if this were a brand spanking new idea never before seen. 350,000,000 here and a very healthy percentage would have no idea what you were talking about with ccsvi>ms, let alone the appetizer platter's worth of corollary issues

When that day comes, and we've been waiting nearly a YEAR now to get even close to the coverage in Canada, this will become a brand new hot topic of discussion, as insurance companies become deluged with claims. Simple numbers game, more population, more patients, bevvy of private insurers all with their unique coverages, it's going to be interesting times as they say. Canada was a bit simpler from that standpoint, as their pen(s) creates quite broader strokes than the US...