Legislation creating Medicare was passed in 1965 and enrollment began one year later, in 1966.  Nobody knew if Medicare would be a success or failure. Would seniors enroll in the program? Would doctors and hospitals participate? Would the country be destroyed by this socialist program?

Five thousand people were hired by the government to go door-to-door to enroll people, 65 and older, into the Medicare health insurance program. The Part B premium was $3 per month, and many seniors said they could not afford to pay that much. (The monthly premium is $104.90 today.)

The American Medical Association (AMA) ran ads condemning Medicare, saying it would lead to socialized medicine. Ronald Regan was hired by the AMA to speak out against the legislation, and he predicted “a thousand years of darkness” if Medicare was implemented.  Here is more of what Ronald Reagan had to say about Medicare:

One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. . . . We are against forcing all citizens, regardless of need, into a compulsory government program….the consequences for “our children” would be dire: “we will sentence them to take the last step into a thousand years of darkness.”

The Washington Post has an interesting article that looks back on the startup of Medicare in 1966, titled, “When Medicare launched, nobody had any clue whether it would work”.

The doom and gloom predictions over Medicare in 1966 seem very similar to the anti-Obamacare talk today.  As it turned out, older Americans appreciate Medicare and know how important it is to their health – and to their financial well-being.

Only time will tell if the more than 30 million Americans without health insurance will sign up for coverage in 2014.

Will there be too many patients for the the number of doctors?  In 1966, anti-Medicare voices said hospitals would be overwhelmed with old people wanting care. That didn’t happen.  Ronald Reagan said we would be plunged into a thousand years of darkeness. That didn’t happen either.

“My friend told me lots of doctors are no longer taking Medicare patients”.

This is a statement I have heard from quite a few people who are turning 65 and signing up for Medicare.  The truth is that over 90% of doctors accept Medicare, and probably 99.9% of hospitals accept Medicare patients.  A while ago I wrote about a study that was done on this subject back in 2011.

In Tucson, and in many cities, some doctors are moving to “concierge medicine” where they don’t take any insurance plans and patients must pay a yearly fee to see the doctor. I don’t get this concierge concept since primary care doctors don’t do much for their patients when they have serious health problems – they refer them to a specialist. And how many times per year does a person see her primary care doctor?

There may be some doctors who are not taking any new Medicare patients because they have too many patients. Or, they want a certain percentage of their patients to be paid through Medicare while the rest would be paid through employer health insurance or other private insurance. That is a business decision.

Here is an article provided by the Regional Director for Medicare, David Sayen. He explains what the ramifications are if a person’s doctor decides to opt out of Medicare.

What does it mean when a doctor tells you he or she has “opted out” of Medicare?

An opt-out doctor is one who doesn’t accept Medicare. Doctors who have opted out of Medicare can charge their Medicare patients whatever fees the physicians choose. These doctors don’t submit any health care claims to Medicare. In addition, opt-out doctors aren’t subject to Medicare laws that limit the amount they can charge their patients.

More than 1 million health care providers throughout the United States – the vast majority of them doctors – accept Medicare as payment.

But when you visit a doctor who has opted out of Medicare, you pay the entire cost of your care, unless it’s an emergency or you need urgent care. Generally, Medicare doesn’t pay for health care services you receive from an opt-out doctor.

If your doctor has formally opted out of Medicare, he or she must have you sign a private contract stating that you agree to receive care from a doctor who doesn’t accept Medicare. This private contract only applies to services provided by the doctor or other provider who asked you to sign it.

You don’t have to sign a private contract. You can always go to another provider who does take Medicare. If you do sign a private contract with your doctor or other provider:

·       Medicare won’t pay any amount for the services you get from this doctor or provider, even if it’s a Medicare-covered service.

·       You’ll have to pay the full amount of whatever this provider charges you for the services you get.

·       If you have a Medicare Supplement Insurance (Medigap) policy, it won’t pay anything for the services you get. Call your insurance company before you get the service if you have questions.

A physician or other provider must tell you if Medicare would pay for the service if you get it from another provider who accepts Medicare. Your provider also must tell you if he or she has been excluded from Medicare.

And keep in mind that you can’t be asked to sign a private contract for emergency or urgent care.

You may want to contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider. Your local SHIP number is available by calling 1-800-MEDICARE (1-800-633-4227).

Most doctors, providers, and suppliers accept Medicare, but you should always check to make sure. (You can always get services not covered by Medicare if you choose to pay for them yourself.)

Providers who participate in Medicare have signed an agreement to accept the Medicare-approved payment for all Medicare-covered services. In other words, they “accept assignment.”

Providers who participate in Medicare have signed an agreement to accept the Medicare-approved payment for all Medicare-covered services. In other words, they “accept assignment.”

Here’s what it means when your doctor, provider, or supplier accepts assignment:

·       Your out-of-pocket costs may be less.

·       Your provider agrees to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share.

·       Your provider has to submit your claim directly to Medicare and can’t charge you for submitting the claim.

David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, Nevada, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

Preventives screenings are covered by Medicare and they are covered by all health insurance plans as a result of Obamacare.  This means a person should have no co-pay and no deductible cost when getting a preventive screening test.  So what should you do if you get a bill?

Last week I wrote about how a colonoscopy turns into a billable procedure. But then a friend of mine told me she got a bill for her colonoscopy even though no polyps were found. So why did her insurance require her to pay $336 for this preventive screening test?

We checked her insurance plan details and she has a $300 deductible on her employer policy. This is very good health insurance because it has such a low deductible. Then I looked closely at the bill she received from the surgery center – and I saw the procedure was called “diagnostic” rather than “routine” or “preventive“.  Ah ha!  There was the reason for the bill!

Because the test was labeled “diagnostic” my friend would have some co-pay. And because her insurance has a deductible, she would have to pay an amount up to her deductible.

The bill says the colonoscopy cost $1,300.  Of course the insurance company doesn’t pay this price because they have a contracted price of $540 according to the bill.  So UnitedHealthcare paid $204, and the patient got a bill for $336. After the deductible she has a 15% co-insurance, which amounted to $36. Still a good deal – except that she should not have had any bill for the preventive screening colonoscopy.

We called her insurance company and asked about the claim coding. The very helpful customer service rep at UnitedHealthcare said there should have been two codes to explain why the test was done, but she saw only one code in the billing record. She gave us the phone number for “provider services” and told us to give it to the billing department at the surgery center.

We called the surgery center and told them to resubmit the bill with the correct codes- and to call United if they were not certain which code to use for “preventive screening”.

Hopefully all this will get fixed. Only time will tell, I guess.

LESSONS LEARNED:

1)  Everyone needs to understand how their health insurance plan works: what your plan’s deductible is; what the co-insurance is; what co-pays are.

2) Understand what preventive screenings are and how they can end up as something more.

3) If you get a bill, read it thoroughly so you can tell if there is a reason for the bill – and that the reason (as in the billing code) is correct.

4) Call the Member Services number on the back of your health insurance card and ask your insurance company to explain the bill and help you figure out how to fix a mistake – or if there was not a mistake and the bill is correct.