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Medical Forum / Diseases and Disorders / Prostate Cancer / October 2005Medicare-PSA
Anybody have experience with Medicare refusing lab bill payment for a PSA done after a period of antibiotic treatment to determine if biopsy was justified as a result of previously detected increasing PSA levels found in routine blood work? > Anybody have experience with Medicare refusing lab bill payment for a PSA > done after a period of antibiotic treatment to determine if biopsy was > justified as a result of previously detected increasing PSA levels found in > routine blood work? It is my possibly-mistaken understanding that, when the patient has *not* been dxd with PCa, Medicare will pay for a PSA test only once per year. Lucky me, I've been dxd with PCa, so Medicare pays for a monthly test. OTOH, the test only costs ~$35. Regards, Steve J > It is my possibly-mistaken understanding that, when the patient has *not* > been dxd with PCa, Medicare will pay for a PSA test only once per year. > > Lucky me, I've been dxd with PCa, so Medicare pays for a monthly test. > > OTOH, the test only costs ~$35. That sounds like a reasonable explanation. Better than the run around I got from Medicare and the lab. They each referred me back to the other and kept responding that Medicare does not pay for a "routine " exam. Didn't seem "routine" to me and the lab is billing $112!! Guess I don't have to worry about payment for future PSA tests with my new diagnosis :-) However, since my son is an attorney, I'm going to give that lab a little extensive static before finally paying that outrageous bill. Thanks for your response. > Anybody have experience with Medicare refusing lab bill payment for a PSA > done after a period of antibiotic treatment to determine if biopsy was > justified as a result of previously detected increasing PSA levels found in > routine blood work? Your Medicare statment should have had an explanation of why the claim was rejected. That would have been determined purely by the diagnostic code the lab used when they submitted the claim. It may be that the lab had a choice of another code. Have you asked your urologist about this? Repeated PSA tests are necessary in the diagnosis and treatment of several conditions involving the prostate. A routine test is restricted to once a year, not only by Medicare, but by many private insurance plans. But your urologist actually treated you for prostatitis, if you were given an antibiotic, and the purpose of the test was to see if the treatment worked. I find it hard to believe that a test for such purposes would not be covered by Medicare. Perhaps you can get hold somewhere of all the different possible codes and get the lab to resubmit the bill under the right code. Medicare lab bills need a diagnosis code for each test. If the claim goes in with ICD-9code 185.0 Neoplasm,Prostate they will pay. Same for commercial insurance. Steve U I do not, but I have heard horror stories about mistakes made at Medicare. My mother's doc just billed them for $8800 and they 'allowed' $800 and told my mom she owes $4800. But, then that's what you get with socialistic healthcare programs.  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05 PSA .07 .05 .06 .05 non Illegitimi carborundum > Anybody have experience with Medicare refusing lab bill payment for a PSA > done after a period of antibiotic treatment to determine if biopsy was > justified as a result of previously detected increasing PSA levels found in > routine blood work? >I do not, but I have heard horror stories about mistakes made at Medicare. > My mother's doc just billed them for $8800 and they 'allowed' $800 and told > my mom she owes $4800. > > But, then that's what you get with socialistic healthcare programs. Unfortunately, this is what you get with all "managed care". The private insurers can be just as bad as Medicare and, believe it or not, some are actually worse. There's a tug of war going on between providers and insurers. The insurers deny legitimate claims, so the providers inflate their bills to compensate. The problem is exacerbated by providers who outright lie to make more money, and insurers who outright lie to save more money. The providers overbill and hire bill collectors who get paid a percentage of what they collect. The insurers underpay and hire claims adjusters who get promotions and bonuses for paying less. This war has already escalated to the point where the poor shnooks like us who get caught in the middle get hit with whopping big bills for even minor procedures. The best socialized medicine systems (and there are differences between them) at least keep the patient out of the line of fire. Alan > >I do not, but I have heard horror stories about mistakes made at Medicare. > > My mother's doc just billed them for $8800 and they 'allowed' $800 and told [quoted text clipped - 5 lines] > private insurers can be just as bad as Medicare and, believe it or > not, some are actually worse. Yeah, I know. I was just messin' with Heather a little bit. >> >I do not, but I have heard horror stories about mistakes made at > Medicare. [quoted text clipped - 9 lines] > > Yeah, I know. I was just messin' with Heather a little bit. Twit!! I just came on here and saw the first *messin* one......and the green eyes were flashing fire!! (VBG) No....what you get with *socialistic* healthcare programs is any and all medical care you should happen to need......at NO cost!! (snicker) Ball's in your court, so to speak.....assuming you.....nah, won't go there. (G) XX Heather If you two want to duke it out on way off topic subjects, would you please do it in a thread clearly identified as such. As things stand, I tend to stop reading threads like this one (and thus risk missing something useful) once the tit-for-tat gets started (I don't mind a brief to-and-fro, but recently it hasn't been limited to that). SignaturePeter Headland Peter.....we are NOT duking it out. And there were exactly 3 OT posts, which is pretty darn brief in my book. Steve loves to tease me and I do the same back. A bit of good-natured bantering or teasing is a good thing sometimes. We have way too much of the serious side in our lives on a permanent basis. But to keep you happy, I will try and remember to put OT in the subject line should I ever stray from the beaten path again. HF > If you two want to duke it out on way off topic subjects, would you > please do it in a thread clearly identified as such. As things stand, I > tend to stop reading threads like this one (and thus risk missing > something useful) once the tit-for-tat gets started (I don't mind a > brief to-and-fro, but recently it hasn't been limited to that). > If you two want to duke it out on way off topic subjects, would you > please do it in a thread clearly identified as such. As things stand, I > tend to stop reading threads like this one (and thus risk missing > something useful) once the tit-for-tat gets started (I don't mind a > brief to-and-fro, but recently it hasn't been limited to that). Sorry Peter. I too will try to remember to put O.T. in the subject line of my reply. Alan |
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