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Medicare Coverage for HoLEP

Posted , 16 users are following.

james87669
james87669

I have aligned myself with a top-notch surgeon for the HoLEP procedure. I know this surgery is the latest and greatest for BPH and I am excited that I have finally come to an end to my misery.

The one thing I have to get clear in my mind is Medicare coverage

(USA only). I got so caught up with the medical explanation that I clearly forgot to mention the "bill". I know that Medicare covers hospital and surgical expences and the Group that I am seeing has all my insurance info on file. 

Bottom line here is. HAS ANYONE ON THIS THREAD HAD HoLEP WHILE UNDER MEDICARE???

0 likes, 33 replies

33 Replies

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  • lester90053
    lester90053 james87669

    Posted

    The best way to get your answer is to call the insurance company that handles your medicare coverage. If you are covered you will still have to pay 20% of the bill.

    If it is not covered it is because the procedure is too new and is considered by many insurance carriers to be experimental. For the same reason most physicians will not do HoLep because their malpractice policies will not cover it.

    • james87669
      james87669 lester90053

      Posted

      Thank you Lester for your reply. I do not have a Medicare advantage plan. My Primary insurance is through Medicare and I also have a secondary insurer that picks up the rest. You are correct in that "most" physicians do not do HoLEP but I believe the reason for that is that most do not have the skill to do it. Actual practicioners are few and far between at this time as it has a long learning curve. FYI check the Mayo Clinic website under Holmium laser prostate surgery for info. 

      My imediate problem is getting information from Medicare. I have come to the realization that getting anything from this bureaudratic mega system is near to impossible for the average patient. It shouldn't be that way but it is. 

      Basically it is surgery to be performed in a hospital setting (inpatient) and that as well as Dr. charges are usually covered. But I am old school and want a clear head going into this.

    • lester90053
      lester90053 james87669

      Posted

      If there is a big demand for HoLEP more urology surgeons would learn to perform it. But as long as insurance coverage for malpractice will exclude

      it they will stick with old radical methods such as TURP.

  • paul20443
    paul20443 james87669

    Posted

    Yes..... I have Medicare and a Fee for Service Plan.  Had my HoLEP at Mayo in Phoenix..... I was told Medicare (straight Medicare, not Medicare Advantage) won't cover a 15% charge from Mayo, so I think the total was aboutt $2,000 out of pocket for me, but I'd do it again in a heartbeat.  I too had a top surgeon, and glad I did the research to figure it out.  Good luck!
    • james87669
      james87669 paul20443

      Posted

      Thank you Paul, My secondary insurer generally picks up the portion not paid by Medicare. Your answer to my question is encouraging. See my reply to lester90053.
    • Boston2AZ
      Boston2AZ paul20443

      Posted

      Paul - I'm arranging to have my HoLEP done at Mayo in PHX. Can you give me the name of the surgeon who did yours? Thanks!

  • paul20443
    paul20443 james87669

    Posted

    Lester.... I'm no expert, but I doubt any surgeon/hospital would do HoLEP if it were not covered by their insurance.  My research led me to believe it was the amount of training that limited the # of docs doing it.  And, as most Uros probably are paid well for TURP & GL, why not continue even if it is inferior to HoLEP?
    • james87669
      james87669 paul20443

      Posted

      I agree Paul, my mind sometimes gives me more trouble than my prostate. Sometimes I just can't let go of an unanswered question and the rumination begins. Thanks for your reply.
    • lester90053
      lester90053 paul20443

      Posted

      If a doctor is part of a hospital staff and paid by the hospital he is covered by the hospital's professional liability insurance. If a doctor is an independent practitioner given use of the hospital to perform a procedure he would have to have his own insurance.
    • james87669
      james87669 lester90053

      Posted

      This Doctor I am seeing is affiliated with a large regional Hospital Group. 
  • lester90053
    lester90053 james87669

    Posted

    I would not worry too much about the doctor's insurance, He must be covered somewhere along the line or accept responsibility or he would not be doing it.
  • griff1980
    griff1980 james87669

    Posted

    I have taked to two people that have had the holep procedure done at the

    mayo clinic in arizona with medicare coverage.

    they said the costs were $ 650 for office vist  $ 19,000 for holep surgery

    $ 200 dollars for the room for one night.

    so their out of pocket cost was $ 4650 dollars so this might give you an idea

    on what holep surgery might cost you .

    • james87669
      james87669 griff1980

      Posted

      Thank you griff, I really appreciate your looking into this for me. My secondary insurrer should pick up anything not paid by Medicare. Curious to how your contacts faired with the surgery.
    • lester90053
      lester90053 james87669

      Posted

      To avoid possible surprises, please discuss this with your secondary insurer as all insurance plans differ.
  • griff1980
    griff1980 james87669

    Posted

    they had only  great things to say about thier results from holep surgery .
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