Medicare and Costs

[Frigaloon]

Hello,
I've been trying to find an implant surgeon that accepts assignment from Medicare. All of the big name surgeons appear to be using the same process and don't appear to be satisfied with the costs that Medicare allows.

I was speaking with one well known surgeon and his office staff and they kept slowly introducing me to more un-reimbursable fees I would have to pay. Additionally, they would not be pinned downed to costs nor commit to anything billing with Medicare. They just sidestep all questions like that. I became worried that they would just bill the crap out of me and leave it up to me to get Medicare to pay and I eat the rest.

Are there any known urologist surgeons out there that will accept assignment from Medicare to keep costs within their allowable costs? If you used Medicare were the urologists staff working the billing process for you?
Thank you

[Onefizz]

I don't know where you are located, but the urological surgeon I used, Dr. James McBride (Colorado Springs, CO) that performed my implant surgery was successful in getting approval by my Medicare Advantage plan (at the time, Humana, now it is Aetna). I don't remember the exact out of pocket cost, however as I recall, it was under $1000. I tried pills, trimix injections, and a VED. These worked for a while, however once they failed, I learned that Medicare might cover the implant and Dr. Mc bride and his staff were able to get the approval. My only regret is that I did not get it done sooner. I just didn't think Medicare, and especially Medicare Advantage, would cover it.

No regrets now in getting implanted and my wife and I have a great love-life in all aspects! Would do it again if needed!

Best regards,

Onefizz

[1sfman]

I don't think under Medicare's rules a doctor can start adding "fees". They either accept Medicare, or they don't. Depending upon your plan, you may have an office co-pay amount with appointment visits and there can be a co-pay amount with the hospital. This applies to Medicare Advantage plans as well.

I have a United Healthcare Medicare Advantage plan. I had my surgery in January and the only out of pocket expense was to the hospital for $525. They billed me prior to surgery after they got approval for the surgery from United. The only other bill I paid was the $40 co-pay for the initial appointment with the urologist. I've paid nothing else, including the 6 weeks follow-up appointment. That follow-up appointment is a post-op exam and not subject to the normal $40 co-pay amount I have to pay when seeing a specialist (my PCP visits have a $0.00 co-pay).

Your statement "Additionally, they would not be pinned downed to costs nor commit to anything billing with Medicare." means it's time to move on. They have to either accept Medicare (including Advantage Plans), or they don't. My doctor is with Associated Urological Specialists in Chicago, a group of 17 Urologists.

All the best to you going forward.

[cbinspok]

the coding is everything, front desk people are awful now a days. inexperienced and a bit lazy.
my doc was not a high volume but did a good job, had to have a second opt due to infections and ill reservoir placement but medical picked up both operations any out of pocket was tiny. I received a statement from medicare stating they had paid nearly 100 grand for services provided. ( I suspect there was adjustments made to that amount between doctor and government)
fill out your signature so we can taylor our comments to your circumstance.

[Old Guy]

Basic Medicare A will not cover any part of implant surgery. If you pay for Medicare Part B it should cover 80% or more of the cost. If you have Part B and another medical insurance (BC/BS, Anthem, UHC, etc.) your cost should be just the annual deductible of $266.

[Frigaloon]

Basic Medicare A will not cover any part of implant surgery. If you pay for Medicare Part B it should cover 80% or more of the cost. If you have Part B and another medical insurance (BC/BS, Anthem, UHC, etc.) your cost should be just the annual deductible of $266.

I have parts A and B. I'm new to this but from my understanding, Medicare sets allowable costs or limits for each coded procedure. Supposedly, if the doctor accepts "assignment by Medicare" they agree to stay at or under the allowable costs. However, if they don't they can charge whatever they want, receive the allowable re-imbursement, then bill the patient for the rest.

[Old Guy]

Basic Medicare A will not cover any part of implant surgery. If you pay for Medicare Part B it should cover 80% or more of the cost. If you have Part B and another medical insurance (BC/BS, Anthem, UHC, etc.) your cost should be just the annual deductible of $266.

I have parts A and B. I'm new to this but from my understanding, Medicare sets allowable costs or limits for each coded procedure. Supposedly, if the doctor accepts "assignment by Medicare" they agree to stay at or under the allowable costs. However, if they don't they can charge whatever they want, receive the allowable re-imbursement, then bill the patient for the rest.

From a search:

2026 Medicare Part B Costs & Doctor Charges
Part B Deductible: You pay the first $283 in 2026 for services before Medicare begins paying.
Coinsurance (20%): After the deductible, you generally pay 20% of the Medicare-approved amount for services.
Excess Charges: If a doctor does not accept assignment, they can charge up to 15% more than the Medicare-approved amount. This is called a "Part B excess charge".
How to Avoid Excess Charges: Use doctors who "accept assignment" (participating providers). You can check using the Medicare Provider Search tool.

Guess you definitely need to find a doc who accepts Medicare assignment. If a doc does not they should be able to provide a cost breakdown before surgery.