Skip to comments.Medicare Rules
Posted on 10/06/2011 6:02:48 PM PDT by yetidog
An old friend told me yesterday that he was denied needed knee surgery due to his weight...new "Medicare rules." He is hardly obese, maybe overweight like a lot of of over 65s might be. Anyone else run into new "Medicare rules?" BTW he has private insurance, but Medicare (as I well know) takes precedent.
Medicare has no such rule. Period.
Sounds completely bogus to me.
What he may have encountered is doctors that won’t see Medicare patients, which obviously is becoming more common.
Pretty sure not true. There must be another reason.
You are right. At the same time, Medicare has no such rule.
If you are on Medicare, and you decide to purchase private insurance as well, then you will not lose coverage from Medicare. However, what may happen is that Medicare will become your secondary payer, meaning that it will fill in the gaps that your private insurance does not cover.
Some doctors just like to give the patient a bogus excuse. An obese patient is often technically more difficult and maybe he didn’t want to bother. The risk would often be higher for obese patients having major knee surgery because of blood clots after surgery. If a patient has Medicare, the fee is set by Medicare even with a private secondary insurance. A lot of doctors that take Medicare are not doing some of the procedures if the fee is too low.
We are going to see more of this selective rationing of elective procedures. If a doctor is a hospital employee, he might not make any more money whether he does a procedure or not. Might as well go back to the lounge and have a coffee. If the doctor is self employed, he might pass up on the tough cases if he can do easier ones in half the time.
Stop Socialized Medicine
Medicare doesn’t have any rules that I can find, but if your friend has a Medicare HMO, the HMO may deny it on the basis that there is supposed to be a higher complication rate for those who are obese. Recent articles show there has been debate over whether obesity is a reason to deny surgery, with a lot of “no” in the articles I saw. If your friend is not really obese, than it doesn’t make any sense at all.
In the near future I will likely have to have a knee replacement. I have joked that under Obamacare I will probably have my leg amputated, but will get to keep the amputation knife so I can whittle my own peg leg.
There has to be more to this story.
Who recommended the knee surgery to begin with? the patient or a doctor?
If it was a doctor, Medicare and related advantage/supplement plans would probably not turn it down.
If the Advantage is the predominent plan, it may require pre-surgery approval for non-doctor recommended procedures.
Not quite correct. Medicare is primary and the private insurance acts as secondary supplement.
Your friend must have Medicare Parts A and B. He may have Tricare or some kind of employer-based group coverage, with Medicare either primary or secondary if he is past 65 and not covered by Part B yet. Regardless, though, he will be treated if his condition is “medically necessary”.
The 2012 edition of “Medicare and You” (published by the Centers for Medicare and Medicaid Services) defines medically necessary as: “Services or supplies that are needed for the ddiagnosis or treatment of your medical condition and meet accepted standards of medical practice.” That is found on page 139.
Hope this helps.
My guess is that you are right. Many doctors will not take Medicare patients, especially if they were not patients before they were eligible for Medicare. Since operations under medicare require the surgeon to bear all follow on expenses if something goes wrong during or after the surgery, many surgeons will decline cases from people they don’t know their history or have experience with them. I know because my doctor is not taking any Medicare patients that were not patients before they became eligible for Medicare. Additionally, many Medicare patients have a history of not buying part B and not paying any of the co-pays.
meaning that it will fill in the gaps that your private insurance does not cover.”
What some of my doctor clients are seeing since Sept 1 is that if Medicare is primary and denies the claim, the Medigap or secondary coverage will also refuse to pay. Many secondary coverage plans cover retired employees and I do expect to see them disappear next year because of their cost.
I have heard stories of patients being discouraged or denied surgery because they are overweight, smoke, drink, or do drugs. It seems doctors think those patients are not good candidates. However, is it really right for doctors to judge patients instead of treating them? The best doctor I ever knew said he just treated the patients he had in front of him instead of searching for perfect patients- took them as they came. He felt people had flaws and yes some don’t always follow drs orders or do things that are not healthy for them- but he still did his best to treat them.
Patients who apply for limited resources -- like transplants -- will be judged based on their ability to survive the procedure and live a productive life thereafter.
I am a dialysis patient and know that kidney transplants are restricted to those most likely to benefit from them. Unless, of course, there is a dedicated family donor.
This practice seems perfectly appropriate to me.