About LASHUNDA Expertise Billing,Claims, and resolutions to the following insurance agencies: Medicare, Medicaid, Coordination of Benefits, Most Managed Care such as HMO's, PPO's, Medicare Advantage Plans, Governmental Agencies such as Work Comp and Veteran's Administration. I would like questions that are in regards to Billing and Collections from Insurance Companies. I can also accept some questions regarding accounts sent to Medical Collections. Please be advised that I reside in Texas and most of my knowledge is based on how it works in Texas.
Experience I have worked in the Medical field for 15 years. I currently help to coordinate contracts for a physician group in Texas. I am extremely good with resolving issues with commerical insurance companies. I'm an expert in coordination of benefits between Medicare and Commercial insurance companies.
Question I have a patient who is working, so he opted out of his part B benefits. Now Aetna says that since he's elligible, and didn't get it, that all they owe is the 20% they would owe if he HAD medicare (they didn't disclose this, and he's got the coverage with no discounts to their policy premiums). They say he owes the 80% Medicare would have paid if it existed. Is there any way around that? Does he have no recourse other than a member appeal?
Answer Hi Anne. Thanks for the question. Most all plans require a person to take medicare when eligible. The requirement for a person to take Medicare when eligible is usually written in the summary plan description that the person receives. There are things that can be done except I need a few for details to steer you in the right direction.
What does he have medicare for? ESRD, disability, or age
If he has medicare for two reasons what are they?
Does he work, retired, or out on disability?
Is his Aetna a fully insured plan or a erisa (self-funded) plan?
Do you have any idea when Medicare is supposed to be his primary?
How old is he?
Was he a school teacher?
Answer most of these questions and I probably can give you some suggestions.
