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Many people under Medicare are getting surprised by large bills after hospitalizations. In our case we had 3 such cases in the first part of the year with total charges of $382. In essence Medicare Part B (covers out-patient charges) does not pay for what they define as “self-administered drugs” when the hospital administers them in an out-patient setting. Instead they say that Medicare Part D should reimburse you after you pay the hospital bill and submit a claim to your Part D insurer. They also say that since this is a “statutory” provision the hospital does not need to inform you that you will be charged for these drugs since there is language in the MEDICARE AND YOU handbook that explains this charge. Note that since this is a non-covered charge your Medigap insurer also won’t pay this charge. It is totally up to you to pay the bill and then partially collect from the Part D insurer.
The first thing that we need to understand is when we are in an out-patient setting. Out-patient includes emergency room visits and even some over-night stays. The only way to know for sure is to ask.
Here is the wording from the 2013 MEDICARE AND YOU handbook on page 44 (same as the wording in the 2012 Handbook but on page 48):
“Medicare covers a limited number of drugs like injections you get in a doctor's office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or external infusion pump), and under very limited circumstances, certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare-approved amount for these covered drugs and the Part B deductible applies.
“If the covered drugs you get in a hospital outpatient setting are part of your outpatient services, you pay the copayment for the services. However, other types of drugs in a hospital outpatient setting (sometimes called "self-administered drugs" or drugs you would normally take on your own), aren't covered by Part B. What you pay depends on whether you have Part D or other prescription drug coverage, whether your drug plan covers the drug, and whether the hospital's pharmacy is in your drug plan's network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting that aren't covered under Part B. See page 91 for more information.
“Other than the examples above, you pay 100% for most prescription drugs, unless you have Part D or other drug coverage.”
This is the language that allows the hospital to not warn you that you will be charged for these “self-administered drugs”
Based upon this description there are two more hurdles to jump through as I can tell. The first is “are (the drugs) part of your outpatient services.” That is a very tough one for a layman (or even doctors and Medicare coders at hospitals) to determine. I had a polyp removed from my sinus in a hospitalization early this year. The polyp was removed through my nostril while under anesthesia. The doctor applied a topical cocaine solution to my nostrils while I was unconscious to make the surgery easier. That was treated as a “self-administered drug” by the hospital’s Medicare coders. After a funny letter about my not applying a cocaine solution to my nostrils at home and that the application of the topical solution was integral to the surgery (the outpatient service) the hospital recoded it and Medicare B paid for it. Other cases are not nearly as clear (or as funny) as mine was.
Secondly you must establish that the drug is a “self-administered drug” and that is no less difficult. This is not just the drugs you routinely take but basically any drug that is administered other than through the IV tube that you could take at home. In my wife’s case this included her drugs that she normally takes plus several that she doesn’t normally take.
One hospital pushed me to get the drugs she normally takes and bring them to the hospital so she could self-administer them and not be charged for them. While a second hospital that she was transferred to didn’t allow this practice and administered her drugs through their pharmacy at many times the cost of the drug. There was a section in one of the forms that she signed on admission that outlined this practice but it was one on 9 sections tucked away in the middle of that form which was just one form of many she signed well after midnight following a 2 hour ambulance drive to Lincoln from the first hospital. This charge included a number of drugs including an over the counter calcium replacement which was totally unnecessary for an over-night stay.
Mistakes are common. In each case we requested detailed bills and in 2 of the 3 cases we found serious errors in coding amounting to $152. Most of these charges were unnecessary such as the Calcium supplement – but if the hospital can charge $230 for drugs that cost $15 they will try.
My complaint is that Medicare can do as it pleases (even if it poses a tremendous burden on seniors on hospitals and on insurers) – but they must demand that the hospital warn us about the charges and give us a choice about accepting the drug.
(End of Part 1)