Confusion Common in Understanding Medicare Billing
By Tucker Thompson, Collin County LIVING WELL Magazine
You’ve been to the doctor and bills are arriving at home. This article is designed to help you understand the billing “process” and how to decipher what you owe.
Most healthcare providers that see Medicare patients are participating providers (doctors, labs, hospitals, etc) that agree to accept Medicare Assignment and the Medicare “allowable charge” as payment. They ask you to pay applicable deductibles or co-pays upfront and then electronically submit your charges to Medicare and/or your insurance company. Then they wait for that reimbursement before asking you to pay anything else. Once claims are submitted, insurance companies must send their payments back within 10 days. Delays can occur if billing departments are slow to submit their claims or they enter incorrect Medicare codes, requiring resubmission.
Important Note: Call medical providers before seeing them to confirm they (1) Accept “Medicare Assignment” (2) Accept your insurance coverage and (3) What portions you’ll be responsible for. The amount you’re responsible for also depends on your insurance coverage.
With Medicare Part B, patients are responsible for 20% of “allowable” charges and Medicare pays 80%. Medicare supplements can cover some or all of your 20%. Advantage Plans, HMOs and PPOs may or may not even cover the 80% that Medicare normally covers, passing this on to patients in addition to high deductibles and copays. By law, participating providers cannot “balance bill” (charge more than Medicare “allows”). They can be fined up to $4,000 for doing so.
Some healthcare providers see Medicare patients, but are non-participating providers. They do not accept Medicare assignment and can charge you, the patient, 15% over (called excess or limiting charges) the amount they are paid as non-participating providers for certain approved services. They may ask you to pay the entire bill upfront, making you seek reimbursement on your own. Using “participating Medicare providers” can save you time and money.
Courteous calls to each provider’s billing department asking them to review with you the bill in detail can help ensure you pay the correct amount. Ask about “allowable charges,” any “excess or limiting charges” and detail of what your responsibility is.
Tucker Thompson, the author, has worked in the insurance field over 20 years. He’s often a guest speaker on topics related to the ever changing landscape of healthcare laws and medical insurance. His time is also filled consulting with people that just want to review their current coverage to make sure they still have the best coverage for their needs.
