Denial of Care

[Southern_gent]

"After decades of caring for Baltimore’s poor and uninsured children, Dr. Michael L. Zollicoffer, a second-generation Baltimore pediatrician, is himself refused treatment for an ever-advancing cancer diagnosis based on an outdated and unresponsive federal Medicare policy."

https://www.washingtoninformer.com/medicare-denials-cancer-treatment/


This is a pediatrician that used to take care of my grand niece. He is a really great man but Medicare (not Medicare advantage) has denied him life saving treatment. Am I wrong to have thought that Medicare leaves these decisions to the patient and the physician? Does anyone know of the best way to push this through?

[Silent Type]

1. Sorry about doc's illness. But it's about time folks realize Medicare denies claims too. In fact, most insurers

nowadays use Medicare coverage policies as the basis for the majority of coverage policies.

[Sedona]

2. Following...

...

[SheltieLover]

3. He should call his US Senator's office if they aren't rapublicons

[Wicked Blue]

6. Maryland's senators are Democrats

Thank goodness

[Jacson6]

4. It depends on the policy of Medicare.

For example the DR checked me with a blood test for prostate cancer at 48, but Medicare denied it because I was under 50. I paid the bill with a discount.

[Mosby]

7. That's crazy.

I started getting PSA tests in my early 40s. I don't think it's even particularly expensive.

[LeftInTX]

13. They only cover pap smears every other year.

[LeftInTX]

5. The GFM says "Medicare part B termination"

Did he terminate his policy? It wasn't clear. Sounds like he needs radiation. But that should be covered. Usually Medicare will not cover anything that is experimental, but doesn't seem to be the case here. Keep us informed.

My dad had numerous experimental treatments when he had cancer. He got them covered. However, he had insurance, Tricare and Medicare.

[Ms. Toad]

9. I'll have to read more carefully.

I got no insurance in effect, but I didn't see why.

[rampartd]

11. there is a maximum radiation allowed

i'm maxed out for a lifetime. it is an exposure limit, not economic.

not sayimg that is the case here.

[Ms. Toad]

14. It's not a hard limit.

But radiation has the side effect of causing other cancers - so they are very cautious. I was told with my breast cancer it was a one-time thing. With sarcoma, I was told while it is generally true that radiation is a one-time thing, there are circumstances under which they can radiate the same area more than once.

But you're right that is a medical decision, not an Medicare decision.

[Ms. Toad]

8. Something is fishy here.

If this is Medicare, it is almost certainly Medicare Advantage.

But in trying to sort out Medicare v. Medicare Advantage I went to the Go Fund Me page, which says his insurance policy was not in effect when he was supposed to start treatment.

There is a policy related to starting, Medicare - if you apply before your 65th birthday, Medicare will start sooner than if you apply after your birthday. That could result in a delay on when he had insurance. (It isn't well explained, and the policy guidance doesn't reflect the law. I almost got caught being without insurance due to a sooner than anticipated retirement, and the delayed enrollment.)

But that isn't a denial of care - it is simply the start date of insurance. Insurance won't cover periods before the policy starts.

I haven't found a clear story, but this is not simply a story of "Medicare policy" delaying care.

[Southern_gent]

10. My son knows this physician and the person

My son knows this physician and the person who did the gofundme didn't get the situation correct. He does have medicare and a medicare supplemental plan. He does not have medicare advantage and it was a denial by cms for the specific care he needed.

[Ms. Toad]

12. Unless the care has non-covered uses, or is experimental,

An advance review isn't even required for Medicare coverage.

We (n=4) have encountered exactly one treatment that required advance review (cosmetic surgery overlap) in a cumulative total of 65 years of experience.

As a general rule, that explanation doesn't make sense, especially with garden variety distressed like colorectal cancer.

[Silent Type]

16. Doctors know experimental and non-covered treatments will get denied, or they learn quickly.

Medicare will deny claims upon submission when certain drug code and/or other noncovered - services with a high probability of failing guidelines - are submitted.

[Ms. Toad]

17. Which is why, as a general rule, Medicare does not deny claims.

And when the doctor screws up and provides services which aren't covered, Medicare sticks the doctor with the bill.

In 2020, Medicare added a requirement of pre-authorization for blepharoplasty (eyelid lift). She met all of the criteria for medical necessity for the surgery because of how limited her field of vision was because of her eyelids. Her doctor thoroughly documented it. In addition, her eyebrows were drooping into her field of vision as well, so she met the medical necessity for an eyebrow lift as well. That required a second set of documentation.

I'm not sure what happened - maybe the approval took longer than anticipated and the doctor didn't want to reschedule because the case was so clear cut. But whatever happened, on the day of surgery the approval hadn't arrived and the doctor operated anyway.

We were completely unaware of this behind-the-scenes activity. Until we got the letter from Medicare rejecting the doctor's appeal of the denial to pay for the surgery - accompanied by an allocation of costs. The denial was solely because of the lack of prior approval - not of the necessity for the surgery.
Because the doctor was the one who was aware of the need for prior approval - not my spouse - the doctor was forbidden from billing us for any of the costs.

But, as a general rule, pre-approval is needed for only a handful of well-defined medically necessary services; otherwise medically necessary services provided in a manner consistent with the guidelines are simply covered.

But - in any event - that is not the case here. If you follow the GoFundMe thread far enough you get to the doctor's statement: According to the government he was not covered by Medicare Part B at the time the services were scheduled to begin. Why he wasn't covered is not addressed. (He could have missed a payment. He could have applied late enough that coverage hadn't started yet. Medicare could have screwed up and terminated his services for an invalid reason.) But this is not a denial of services event. It is a lack of insurance.

[Ms. Toad]

15. From Dr. Zollicoffer, himself:

I was to start my radiation last week as Mike Haynie had explained in an earlier post. But because of a Medicare part B termination, which is the outpatient portion of Medicare I was told I cannot start treatment.

This is from his own update on November 25.

So the issue isn't a denial of care. Based on Dr. Zollicoffer's own words, it is not a denial of care under an existing policy - but a lack of Medicare Part B (and a supplement - because the supplemental policy is tied directly to having Medicare Part B. That may be due to an error, a missed payment, late enrollment in Medicare if he still had employment related insurance and had to retire quickly and enroll in part B. As I noted earlier, enrollment in Part B is not straightforward, and it was only pure dumb luck that kept me from going without coverage. Coverage typically starts the month after you enroll during a special enrollment period. By specifically requesting it (and knowing that the law permitted it), I was able to have it start the day I applied.

I hope he can find a solution. But this situation should not be used as an illustration of the very real denial of care under Medicare Advantage plans (and other traditional insurance plans) over which there is justified outrage - or to suggest that Medicare suffers from the same issues as Medicare Advantage when it comes to denial of care.