Molly, Duane, June: Medical information, discussion

Molly Janczyk to June Hughes, January 24, 2007

Subject: Know a good Dr. in Hamilton Co.?

The fact that you had polyps should be sufficient alone. I'll ask if anyone knows a good compassionate Dr. in your area. I find that DO's are more holistic in their approach looking for causes and solutions vs simply medicating symptoms. DO's are MD's with further training.

Also, ask your friends and contacts with what you like in a Dr. Too many are hands off with an air. We all want one we can speak with re: concerns. I take ques. written down so I remember everything. If someone doesn't have time, I , too, go somewhere else. I have found very caring Dr.'s as a result.

I hope the same for you.

---

June Hughes to Molly Janczyk, January 24, 2007

Subject: Re: Medical Update!

Thanks, I did have polyps removed waaaaaaay back which were not cancerous. So this present internist Dr is requesting I have another since it's way over time for such. Also I would say age would be part of my argument for one. I'm looking for another Dr which I'm not completely pleased with. Any suggestions to find one who is one who will work with patients instead of ignoring them or try to make one sided (hers) decisions? I do appreciate the information which helps me make a better decision.

June

---

On Jan 24, 2007, at 12:16 AM, molly janczyk wrote:

I believe a colonoscopy now is approved just by age as well. Most have some symptom anyway which can be used.

Just get a pre cert and approved facility and Dr. within network

---
Duane Tron to Molly Janczyk, January 23, 2007

Subject: Re: Medical Update!

Molly,

Tell June that it has been about five years since I had my last colonoscopy. I was having some problems and my doctor was concerned so he requested a precert to have me tested to make sure I wasn't experiencing a new cancer. They approved the procedure upon his recommendation/request. He simply listed my symptoms, my family history, and the fact that I had prior colon/rectal surgery in 1993. June just needs to have her doctor certify that he/she has concerns based symptoms she is experiencing.

Duane

---

Duane Tron to Molly, January 23, 2007

Subject: Re: Medical Update!

All she has to do is have her doctor file a precert that he feels the procedure is necessary due to health concerns and list the reasons why. They will normally accept the precert based on a doctor's recommendation. I was having a number of issues/problems and my doctor became concerned and sent me for testing. The ten year time frame is only a recommendation and not written in stone. My doctor set my schedule at every five years and if, and when, I am experiencing new health concerns/symptoms that could be a possible cancer. She can call and get an opinion and I recommend she speaks with her doctor and asks him/her first. If he/she is in the network they will know what they can and can't do and what is covered and what isn't. My best advice!

Duane

---

From Molly Janczyk, January 23, 2007

Subject: Re: Medical Update!
I am sure it is. After 50, one colonoscopy every 10 yrs. is covered under most plans. A diagnosis is easy if needed by the Dr. for insurance to pay as everyone has some symptom which can be listed. Have your Dr. precert the procedure with your insurance provider. I had one due to age.

There are differences between Medicare and Medicare with state employees.

YES! YOU must pre cert and with our insurance and this is not always the case as Medicare is the most widely used and Dr.s know what is covered and most automatically precert anyway. Dr.s who agree to Medicare know the drill so to speak.

But, our coverage is not as widely used so ALWAYS HAVE YOUR DR. PRECERT AND/OR YOU CALL YOUR INSURANCE PROVIDER TOO SO NO SURPRISES! For ex., we were told John's Dr. is Med. Mut. and most are. They have our card and yet one Dr. in the office is not in network with Med Mut +. It is their error and we are not paying as they have a copy of the card and didn't check.

1. Be sure your Dr. precertifies any procedure
2. Be sure all your Dr.s and overnight stays in any medical facility-hospital and nursing/convalescent care is IN NETWORK!

Those are the 2 differences. You can go to any facility with Medicare only.

STRS is your Part A if you don't qualify for Part A yourself or through a spouse. Part A pays for any overnight stay in hospitals and facilities. ALWAYS BE SURE TO CK THAT THIS FACILITY OR HOSPITAL IS IN NETWORK by calling your insurance provider. Otherwise you will have to pay addt'l out of network deduc. and out of pockets in excess of your in network and deduc. for the year.

Medicare is your Part B.

When you receive bills from hospitals and Dr.s etc., DO NOT PAY them until they go thru Medicare and then thru your insurance provider who will tell you the patient responsibility and you NEVER pay more than that. If anyone tries to bill you more , contact your insurance provider and they will contact the medical source to stop billing you as a contracted member of your provider for insurance.

I can tell you this took much time with my mother's hospital because they are so used to just billing Medicare. They had to rebill 3 times getting it straight that OPERS was my mother's primary for Part A. You do not have to worry about time. Medicare told me 2 yrs. are allowed to process. Medicare will send you their pays and then they go to your provider (Med Mut or Aetna, etc.) and then to you with your patient responsibility which should be low after Medicare and Med Mut, etc have paid. Med Mut or Aetna, etc will pay the remaining 80% and you pay 20% until your out of pockets are reached and then you pay 0. My mom's bills were very low -- a few dollars and up to $70 which was 3 combined visits totaled together for a specialist while in hospital.

Unless you go out of your network, you should never owe more than your yearly deduc. for each person and the out of pocket listed for each person listed by Med. Mut or Aetna or your provider. We have $500 deduc ea. + $1500 each to total $2000 per. My husband always meets this due to his health problems and for the remainder of the year , STRS pays 100% of his costs.

If you chose out of network, a new deduc. of $1000 starts for them and new out of pockets of $3000 each person.

SO:
1. Always precertify any procedure
2. Always be sure all medical providers, facilities ARE IN YOUR NETWORK! Do not listen to anyone else as their coverage may differ. My mother wanted to go to a facility next to her residence and could not. We found their 'sister' facility and she was pleased with it.

**Call Med. Mut. or Aetna or whomever you have coverage with and give the name of the procedure and / or the facility and they will tell you and give you a list of facilities you can use.

Part A: Overnight stays: STRS is our Primary and Medicare is our Secondary so both pay first Part B: Dr., tests: Med Mut. or Aetna, etc. is the Primary and STRS is secondary insurer

---
From: June Hughes, January 23, 2007

Subject: Re: Medical Update!

So Molly was his procedure covered by our insurance? I've been trying to find a definitive answer so I can go forward with my own test. I've read that the Dr is covered by Med B but then there has to be prior insurance permission to have polyps removed. ?? (I dread this test)

June