Medicare Claim Rejected - What Can I Do about It?

Lazngamer on 20/05/2020 - 21:54
Last edited 21/05/2020 - 14:26

Hi everyone, first forum post.

My medicare claim got rejected from a place that was doing bulk billing. It was supposed to be all covered and now I am left with a $400 bill. Wondering if there is anything I can do at this stage. Contacted Medicare and the guy said no, there is nothing I can do about it and referred me to MBS online. Tried looking and don't even know how to navigate.

MBSOnline

Background:

I've had a third heart sound and a lump on my abdomen and a piece of glass stuck in my thumb for couple of months from a small accident. I went to a GP end of last year and was referred to get an Echo-cardiogram as well as Ultrasound for the lump and piece of glass. Fast forward to April, I finally had the time to go to these appointments because the company that I worked in asked everyone to take a week off. I scheduled both appointment on the same day thinking I would start the week off with something productive and schedule a follow up with the GP end of the week.

Echo (Item 55113)

Had an Echo and it wasn't all covered by Medicare. From memory, it was $460 and medicare covered just under half. Turns out I have something that needs to be checked on a yearly basis. I don't believe this is related so that leads me to the final section…

Ultrasound (Item 55800, 55812)

I went to a bulked bill place to have it my ultrasound. I gave them a call asking to confirm if it is fully covered and they said yes. Did the ultrasound and both the guy that did my ultrasound and the receptionist confirmed there were no outstanding payments.

Fast forward now

I received a bill today from the ultrasound to pay $400 because my claim was rejected by Medicare and that was because another company has charged using Item 55113, the Echo that I did on the same day. They noted "for that reason, we've had to change your account to private".

What I need help with

I am not sure what I can do. While Echo and the ultrasound might be similar somewhat, they are for entirely different reasons. I feel that it is my fault for not checking the details of what is claimable but looking through the MBS Online now even with hindsight, I am still lost on how to even verify this. I've tried google-ing the items but I don't know how to connect this items to verify that they are the same thing at least from Medicare point of view.

Edit: I thought I formatted the link correct, but looks like messed it up. Link for MBSOnline is : mbsonline.gov.au

Edit 2: The glass in my thumb was something recent, the heart and lump has been there for years but finally had it checked.

Update after calling the practice

Spoke to the manager, she said they have tried multiple times to claim. While they are claiming it on different dates, they still need to state the date of the test (as stated by pineapples) and that's what Medicare is basing their rejection on. Fact is that the practice is not getting money from this procedure. We settled on half. While it is still a pretty big financial hit, it was better than the initial price.

Lesson learnt

Lesson learnt from all this was to disclose all medical procedures if they were done roughly the same time. Without proper knowledge on how the MBS online works, I would be more wary of the cool down period and just disclose more info just to avoid situations like this.

I would like to thank all the helpful comments given here. You guys managed to turned a what seemed like nothing can be done situation into something better. I am very thankful for that.

For any medical people here interested in my conditions as a case study, I am happy to provide the details in a private message. PM me and I just request to have it kept outside the forums.

In terms of resolution of this forum, I would like to keep this open a bit longer if someone can shed some knowledge on the MBSOnline.

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closed Comments

[Deactivated] on 20/05/2020 - 22:08

+3

Sounds like you cant do much given medicares advice. Seems the horse has bolted on this one.
Hope you stay healthy.
- azngamer on 20/05/2020 - 22:14
  
  Thanks.
  
  I see why they would want to prevent charges from same items but at the same time to prevent people from exploiting the system. But I wish I could understand a bit more about the link that they referred me to.
  
  Touch wood that I have kidney failures, both of them on the same day at different instances and get slapped with a massive medical bill because Medicare rejected my second item on the same day. Nuh uh, no second kidney surgery until I can understand the MBSOnline!
  - Pineapples on 20/05/2020 - 22:21
    
    You'd be able to get both kidneys ultrasounded at the same time - they're included in an abdominal ultrasound. But I get your point.
Pineapples on 20/05/2020 - 22:19

+2

There are places that bulk bill echos for future reference. There are definitely item numbers that can't be billed on the same day. I'm not sure if this will work for your situation, but ask the radiology place to put through the medicare item number again, but mark it as not related to the previous billing that day. The reason they wouldn't have noticed straight away is that not all medicare billing is instant, especially if you're bulk billing. All of our medicare payments go through at the end of the day, so we don't know if they'll get rejected til then. Even so, we can get notification from medicare down the track that the billing has been rejected. (Disclaimer - I'm not an expert on the topic and some of those details might be wrong. Our practice manager deals with all of that stuff)
- Pineapples on 20/05/2020 - 22:29
  
  Also not sure why they are billing you $400 for an ultrasound. That's way over the medicare rebate
  - John Kimble on 20/05/2020 - 22:50
    
    +1
    
    Because they have a working air-conditioning unit they need to maintain :p
    - Pineapples on 21/05/2020 - 08:08
      
      +1
      
      Radiology practices are always so cool. I'm mad jealous of their aircon
  - azngamer on 20/05/2020 - 23:14
    
    Thanks. I will keep an eye out better for bulk billed echo. I went through a small list of recommendation by my GP then settled on one. It would be very useful for future yearly check ups.
    
    I will give the ultrasound a call tomorrow and follow as per your advise. Thanks for sharing how things work with medicare billing works.
    
    As for the bill, it was $200 to check the abdomen for the lump and $200 for the FB in my thumb.
    
    Thanks for the advise
- HardQuiz on 21/05/2020 - 03:50
  
  Can you bill (send to Medicare) after a day or 2 of the ultrasound?
  
  Would that help the OP if the practice/imaging sent another claim to Medicare or they should send an amendment to the old claim ?
  - Pineapples on 21/05/2020 - 08:07
    
    It would probably be fine if it was billed the next day, but you have to bill medicare for the service date. You can lodge it after that date, but it has to be requested for the date the scan was done. Silly system for situations like this.
Almost Banned on 20/05/2020 - 23:41

+4

I would inform the bulk-billing practice that you enquired multiple times whether there would be any out-of-pocket for the ultrasound and was assured each time there was no charge.
I would inform them that had they told you there would be a charge you would have scheduled it differently.
I would point out that on leaving the practice they confirmed the matter was completed.
I would then let them know that you have no liability to pay their bill.
Then I would see what happened.
- azngamer on 20/05/2020 - 23:59
  
  Thanks for the ideas on the approach. I will probably do what pineapple suggested and add in the first 3 points you made.
  
  As for the last point on the me having no liability to pay the bill, I don't think I am comfortable saying that since they are on the assumption that the medicare didn't reject the claim. It is probably rare for someone to squeeze all check ups in one day and probably not worth asking a whole bunch of questions for everyone that shows up.
  
  Is it within the medical practice responsibility to be so thorough with making sure medicare claims don't get rejected?
  - Pineapples on 21/05/2020 - 08:05
    
    +1
    
    It's a tricky one. Again, if its anything like general practice - it would've looked like the claim should go through given you had a valid referral, valid medicare card and hadn't had any other scans with them that day. Devil's advocate - I've never heard of a radiology practice asking if you had scans anywhere else that day (but maybe they should). Without OP disclosing that they'd had an echo that morning, there's no way for them to know that the claim would be rejected until medicare got back to them (wouldn't have been on the spot). That being said, it wouldn't have occurred to me to let them know about that if I was in your situation.
    
    If you get stuck with the receptionist, try the practice manager. If you absolutely get stuck paying, definitely don't pay any more than the MBS fee - should be less than $200/ scan. You could even try lodging the claim straight to medicare with the invoice (unlikely to yield much success). If you have health insurance, there's a slight chance they might pay some of it.
    
    I'm guessing the reason they could bill your abdo and thumb USS the same day is because they were separate issues. Not sure why this wouldn't apply for the echo. Good luck - let us know how it goes! Again, not an expert on radiology billing, but we can definitely bill incompatible items on the same day in general practice if we flag them as being not related to each other. It doesn't take us more than a couple minutes to lodge a claim with medicare (unless its different if its been rejected previously), so it shouldn't be a big effort for them to try that.
- whooah1979 on 21/05/2020 - 11:56
  
  Medicare didn’t pay the bill so the liability falls back to the customer.
  - Almost Banned on 21/05/2020 - 18:14
    
    +1
    
    If I tell you that you can have a free car because someone else has paid for you, we sign the paperwork and I give you the car, and you drive away with it - can I then tell you a month later than you owe me $100,000?
    If not, why not?
    - whooah1979 on 21/05/2020 - 19:54
      
      The difference in you scenario is that someone has already paid for the vehicle.
      
      The customer in this thread used a service that was to be billed after the service was rendered. The customer has a responsibility to make sure that they’re eligible to pass that bill to Medicare.
      - Almost Banned on 21/05/2020 - 20:10
        
        @whooah1979: No difference. The 'someone else' in my scenario never paid.
        Feel free to change my scenario to 'paint your house' if that helps.
        Why would the customer be expected to know whether there would be any gap charge (or total charge) when the MEDICAL PRACTICE has specifically told them there is no charge?
        Why should the customer bear the cost of the medical practice's bad advice, especially when had the medical practice given the correct advice the customer could easily have scheduled the procedure for another day?
        The cost is laid on the customer only because the practice misled him/her. In this country you don't get to benefit from misleading consumers.
AdosHouse on 21/05/2020 - 00:09

I know it sounds like a stupid question, but you had referrals for all these, right?
- azngamer on 21/05/2020 - 00:11
  
  Yes, my GP gave me referrals for all these checks.
brendanm on 21/05/2020 - 06:47

+1

Seems pretty stupid that it you have referrals and made sure they bulk billed, you got charged. I would have done the same thing and got it all out of the way at once.
- azngamer on 21/05/2020 - 14:50
  
  Yeh, unfortunately it's not a very common situation. Medicare has their strange rules, I didn't disclose other claims and they didn't ask.
  
  Lesson learnt! Disclose other procedures just go be on the safe side.
holdenmg on 21/05/2020 - 08:21

-2

This makes me wary of going out for a Burger, Fries and a Coke on the same day at the same place.

If I spread this over three days, either the Coke will go flat or the food will be cold.

Plus no Combo discount.

MBS Online said Burger, Coke and Fries w/Salt are bad, I'll need Extras for Beetroot or an Egg.

They won't take Medicare with or without a referral either…

I want to be on a McDiet, I think I need a Bulk Billing Dietitian….
azngamer on 21/05/2020 - 11:38

+2

I've called the practice. I've updated above.
Pineapples on 21/05/2020 - 19:12

In regards to your update, sounds like a reasonable resolution. Did you have any particular questions on MBS online? I struggle to navigate it - and it's not really designed for your average non-medical person. If you want to see what has been billed to Medicare under your name, you can see that on the Medicare website
- azngamer on 21/05/2020 - 19:23
  
  With the MBSOnline, I was hoping to find connections to item numbers.
  
  When I got off the phone with Medicare, I was referred to this site. My understanding was that this website would let me know where it states that those item claims clashes. Under the impression it was going to be some sort of pds.
  
  If for example in the future, I need to take a blood test, a chest xray and an echo, would I be able to schedule them on the same day or do I need to space them out. And if I do space them out, where can I find the cool off period?
  
  Terrible example, but while they are entirely different procedure, so was an echo and ultrasound (even though they are both using an ultrasound machine). I was hoping to find how Medicare draw the lines.
  
  I might be very wrong and misinterpreted what Medicare told me over the phone.
  - Pineapples on 21/05/2020 - 20:11
    
    +1
    
    I get where you're coming from. Bit of a cop out (in my opinion) for Medicare to expect laypeople to understand the MBS. I'm not aware of blood tests being incompatible with any other test - it's usually imaging. Your best bet is to ask the imaging place - they usually have a pretty good idea