medicare rates for jpouch surgery

quote:

they will only reimburse 60% of 200% of medicare's rate

Isn't that the same as 30% of Medicare's rate? Or have my math skills eroded?

I dont think so. If you use $100 as the rate, 30% of that would be $30. However if you take 60% of 200% of $100 you get $120. .60 x ($100 x 2)= $120. Someone else see it another way? Why does Medicare reimbursement have to be so complicated??

Have you tried to google and see if you can find it?

That actually amounts to 120% of the medicare rates. I did try gogling but got nowhere

I would call medicare and ask for their help. Or ask the doctor's office manager. Also the hospital should be able to help you for their medicare rates.

Does your insurance cover the hospital, anesthesiology, tests and hospital room rates etc.? Find out what the surgeon's charge will be and it should be much less than everything else.

If I were you I'd find another surgeon. That's just my personal opinion as I don't like doctors that don't take insurance or medicare patients. If he's the best then it's an investment in your future. Do you have a Health Savings Account, with your insurance, that you pay into? You could use the money in there to pay him. I think you might be able to use the flex plans to where they withhold so much from your paycheck and if you don't use it all on medical expenses during the year you loose the unused funds. Since the beginning of the year is coming up you could fund your HSA for 2012 and after 12/31 fund for 2013. At least that way you would get to deduct the amount you pay into the HSA on your income taxes, even if you do not itemize.

I wonder if your insurance covers the Cleveland Clinic? Maybe the travel costs would be more than the cost of the NY surgeon.

Sorry I got so carried away, I've just dealt with this a lot. Sorry if I explained things you already know about.

Good luck!

It's often reasonable to choose a colorectal surgeon who doesn't accept your insurance company's price (whether that's based on Medicare rates or not). If 1) you're convinced it's the right surgeon for you, and 2) you can afford the higher out-of-pocket costs. I do suggest you make certain that the hospital and anesthesiologist will accept your insurance, though, as the hospital costs in particular are unpredictable and can grow very large.

I recently had a hysterectomy. My ObGyn does not take Medicare and I pay her a discounted rate for office visits, exams, etc. I do so because she is that good. When I started seeing her, I told her up front that if I ever needed surgery, I would need a referral to a surgeon who took Medicare. Well, she did just that and I was extremely pleased with the ObGyn surgeon she sent me to. Surgical procedures are too expensive to have without doctors who take your insurance. Ask for a referral.

I believe the hospital charges will be covered by the insurance but not so sure about the anesthetist. I will ask the details when I meet they surgeon on the 31st. I just wished that things were simpler and all doctors just accepted d insurance. If UC wasn't enough, now we need to deal with all these hassles.

One last thought. Do you have out of network coverage? Ours will cover those costs above double our regular deductible. Hopefully he doesn't charge that much.

Good Luck and please let us know how you are doing.

My daughter's Dr. is out of network. In the past, I asked the office for the procedure and diagnosis codes and then called the insurance to see what they would pay. Insurance also has their reasonable and customary charge amounts they pay.

Best wishes.

Yes, I do have out of network coverage. I think it is capped at 200% of medicare rates. Also, it has an out of pocket maximum of $4,000. I am not sure if that means that any surgeon's fee above that $4,000 would be covered by the insurance company.

Beckysmom - Thanks for the advice. I will call up my doctor's office tomorrow and get the codes.

Ooops...I meant 60% of 200% of medicare rates.

"Out of pocket maximum" most commonly refers to an annual cap on your total copays (and generally deductibles). Yeas, they stop charging you copays after you reach that amount. There might be a maximum on an individual hospital stay, but that would be unusual. *However*, the out of pocket maximum rarely applies to out-of-network fees higher than whatever the insurance company deems acceptable. So your actual out of pocket would be up to the insurance cap plus the difference between the billed fee and the insurance company's top fee.