MDS SCT and Medicare

[rar]

I had a stem cell transplant for my MDS. Medicare denied payment on the SCT stating that they only pay if you have an approved clinical trial before your transplant. It went on to say that even though they would not pay, I was not responsible to pay either. I did participate in a trial that is listed on clinicaltrials.gov as still recruiting.

The charge for SCT was $131,000. Medicare paid all other expenses including all expenses while I was in hospital for the SCT. So far the total bill charged by the hospitals and doctors came to $1,188,000. Medicare negotiated payment was $161,000.

Do other patients have similar problems with Medicare denying charges?

With Medicare paying about 14% of the charge master amount are the hospitals losing big time on treating Medicare patients? If so why accept them? Or are the hospitals making 700%+ profit on those unfortunate patients without insurance?

Ray

[DanL]

Ray,

Many insurance companies have similar negotiated rates with the hospitals where there is a stated price and then a negotiated price that covers all costs associated with the immediate stay tied to transplant.

It is kind of treated like a wholesale price versus a retail price. In addition to that, there is a so called cash, negotiated price that patients can pay if they pay in advance of service. To complicate matters more, there is a financial means test that every patient is supposed to go through in order for hospitals to be able to recover funds for tax losses and ACA compliance.

To sum up, the stated retail price is almost never the price paid, but not everybody pays the same price.

[rar]

Hi Dan,

I agree that insurance never pays charge master prices. When it comes to individuals hospitals charge full list price. As an example I requested a blood test, doctor agreed that I should have it. I went to hospital and was told that I would have to pay $233 up front to have it done. I was told Medicare would not pay on the code the doctor gave. I asked what is the proper code. They refused to tell. I went back to the doctor and they tried a different code. It went through and Medicare paid $18.32 for the test. I had other instances where I was improperly billed and it was always at full list price.

Has anyone else have SCT claim denied by Medicare?

Ray