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Va Reimbursement For Medicare Deductible Emergency Room

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Tbird

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long story short friday i called va emergency room rectal bleeding sever pain to the point of passing out, emergency room nurse says va is diverting they have no beds, but she doesn't know if they va pays or not. i call 911 they check their system the va has not put it in the emt system that they were on diversion, so the emt called the va and they told him they were on diversion, there was some back and forth about it needs to be in their system. and then they took me to a civilian hospital slu saint louis university hospital, we'll just call it slu. so my colon is inflamed and swollen and the bleeding was not stopping. they check me into the hospital on friday and i check out on wed, diagnosis ulcerative colitis. when i got to the emergency room on friday they asked what my insurance was we gave them my va card and stated it was my primary and we gave them my medicare card.

so's the civilian hospital slu wants me to pay the medicare deductible and i says the va needs to pay it, they need to bill va, they says they don't bill va, because va won't pay the deductible. i call fee basis at the va and they say slu bills us all the time call them back, so's i call slu back and tell's 'em what the guy at fee basis say and they say again that they won't bill va for medicare deductible because the va won't pay it. so's i call the patient advocate and she say's the va can't legally pay the medicare deductible, but i say you guys diverted me and i'm a 100% veteran. and she says that's the problem with giving them your medicare card and i says do you want me to lie and she says no i am in no way telling you to lie, but what should i do then and we just go round and round till she tells me when i get the bill to submit it to fee basis and a determination will be made by them.

what kind of crap is this? i says to the lady this sounds like a scam, it sounds like you understaff your er, so vets get diverted to civilian hospitals and you don't have to pay those bills, she assured me this was not the case. but i'm just suspicious that way, too many years in the system, ptsd, maybe a combination of both.

so waiting for the bill for the medicare deductible which i will take to fee basis and make the claim.

the doc wants to come back in two weeks for a follow up but i can't afford that.

any advice would be welcome.

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Wow.....First of all, I sure hope you are feeling better.

Second....this sounds really familiar to the runaround the Datyon VA fee-based office is trying to pull with me. Basically, you are right. The VA must pay. It was an emergency, you are 100%...end of story. You have to get a copy of all of your hospital records for when you were in the real....er...civilian hospital and submit a copy to the fee-based office for them to determine the claim. At the same time, submit a 2nd copy to your PCP and request fee-based f/u care. Do this ASAP!

It is very possible that the VA will not pay for your f/u appt. They are telling me that they are not going to pay for mine.....but I have news for them; they are, they just don't know it yet.

In my case, the emts told me that they don't ever transport to the Dayton VA because they have been briefed that it's nothing more than a "clinic" and they are never to transport anyone there! LMFAO!!!!

Stand firm with your fee-based office...keep good notes...go over their head if you have to.

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tbird, VA is responsible for the whole bill, thru fee basis. VA is not allowed to pay the medicare deductable. VA pays all or nothing and is not allowed to be secondary payer, by CFR. Since you're a VA patient the hospital has to bill the VA but will try to do medicare, w/copay, cuz they get more and it's easier. SLU is required to notify VA that a VA patient is there, setting up for fee basis. Once fee basis is notified they are supposed to try to get you to VA, if possible. Talk to whoever is in charge of SLU's billing dept.

See 38 CFR 17.52, 17.53, 17.54 & 17.55

pr

Edited by Philip Rogers
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I have had good luck with Dayton Va medical Center, with only a few minor exceptions. I had no problem once, when Dayton VA was full and diverting, and they sent me to a private hospital. They paid the bill, no problem. It was an emergency as I had chest pains.

I think yours will be ok also.

Something I might recommend is this:

Remember, the right hand does not know what the left hand is doing in the VA. So, just go to their Fee basis department, tell them they were diverting, and they need to pay this bill. Chances are fairly good you wont get the same person you had before, and they will do it differently.

If you go to one person and they say no, just call back in a few days when someone else is there, and you will likely get a different result with a different person.

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Tbird,

I think you should also call your PCP at VA and let them know you have that

follow-up visit so they can get it pre-authorized from fee-basis.

We missed you and are glad your back where you belong for now, home.

FYI - This whole issue is why years ago,I declined acceptance of medicare.

I guess I prefer if a doctor's going to get the chance to

not save my life - I'd rather let a VA doc do it - LMAO.

carlie

carlie

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i talked to slu till i was blue in the face and they say they won't bill the va, because the va doesn't pay what medicare pays and since i had medicare and i had both they billed medicare.

i think this is very screwed up and i do have a follow up at the clinic and not sure what to do. slu will not budge on the billing issue.

thanks for the cfr references i've printed them out and will be going through them tomorrow.

my stomach is tightening just thinking about it, ugh

tbird, VA is responsible for the whole bill, thru fee basis. VA is not allowed to pay the medicare deductable. VA pays all or nothing and is not allowed to be secondary payer, by CFR. Since you're a VA patient the hospital has to bill the VA but will try to do medicare, w/copay, cuz they get more and it's easier. SLU is required to notify VA that a VA patient is there, setting up for fee basis. Once fee basis is notified they are supposed to try to get you to VA, if possible. Talk to whoever is in charge of SLU's billing dept.

See 38 CFR 17.52, 17.53, 17.54 & 17.55

pr

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TBird, Please do not give up! Contact Medicare and tell Medicare this bill should have been sent to VA. Medicare will request the money back from the provider. Call the provider and let them know Medicare is going to ask for the money back. The VA won't pay a deductible. The VA pays less than Medicare plus your part, so of course the provider prefers that. Call your patient rep (aka known as the Director's

cushion)and put in a formal complaint. Let him/her know you have reported to Medicare the bill should be sent to the VA. I deal with this a lot and it takes a LOT of my time. Medicare is easier for the provider to file, but stand strong and make the VA pay what the VA owes!

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