Medicare services and coverage plans are not all created equally. You may have a bill show up in your mailbox that has an amount much higher than you expected. How can you avoid this situation, or at least be prepared for it?
We recently asked two Medicare experts for answers and opinions on popular questions and topics. The following questions and answers were transcribed from our interview posted on YouTube. The Medicare experts we interviewed were LaMonica Thomas and David Ireland.
What Services are Offered by Medicare?
LaMonica Thomas: There are a lot of great benefits offered through Medicare but keep in mind Medicare Parts A and B will cover 80% of most hospital, doctor, and outpatient services. Some of the other benefits will include
Skilled nursing services
Lab tests & services
Home health care
Ambulance and emergency services
Education on Medicare is so important, especially when it comes to services that may not be covered. Some healthcare organizations will try to take advantage of seniors who aren’t covered for a certain procedure or test. Asking yourself things like ‘what is this for’ or ‘why am I getting this done’ can help you avoid unnecessary procedures.
Why am I Getting Charged on Medicare?
David Ireland: Bills are bills. They are always frustrating even if you\’re expecting it. Sometimes, however, you can get an unexpected bill that just makes your eyes pop out of your head.
Medicare Billing Errors
First things first: It may just be a simple mistake. The most common reason we see for unexpected Medicare bills is from coding errors. So, as you\’ve probably been able to tell so far, differentiating between insurance and Medicare is kind of confusing and it’s a whole another level on the back end.
Billing consists of a whole lot of codes, so every time you go to a doctor or a hospital, there\’s a code associated with that. Oftentimes it\’s multiple codes. Providers submit these codes to either the insurance company or Medicare for reimbursement. Sometimes people make mistakes which can result in overcharging or even a flat flat-out claim denial.
My first recommendation if you get an unexpected bill is to call the number on the bill and ask why the amount is different than you were expecting. Often this is a simple fix and nothing to worry about.
Appealing Medicare Billing
If you receive a large bill and there were no coding errors, however, you have a right to file an appeal with Medicare. The appeals process will be spelled out in your plan documents as far as how you go about doing so.
Basically, you appeal with the insurance plan that you disagree with how it was covered. They might very well take care of it, especially if you have a Medicare supplement or an Advantage plan–which make it clear as to how much you should have to pay for any given service.
Remember: Although Medicare covers 80% you\’re still responsible for 20%. 20% of what, however, can be a great question to ask. That bill that looks really high, it might be the 20% is costly and legitimate because you had a really expensive service or procedure. Always remember to closely look at estimates and potential expenses beforehand.
Medicare Explanation of Benefits
There\’s also something else called an explanation of benefits. You may get a statement in the mail–it\’s not a bill, but it will show the full amount, provider charge, the amount the insurance company agreed to pay, and a balance. Sometimes these statements can be hard to read and misinterpreted. If a person looks at the total amount (not what they have to pack out-of-pocket), they may be stunned at the total cost.
A final note: If you receive a bill from an extended hospital visit (maybe you stayed overnight or a few nights) you may be considered inpatient versus observation. Hospitals can miscode this, which Medicare may then ‘misbill’ due to incorrect information.
Charlin Health Services
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About the Medicare Experts
David Ireland is a marketing director with The Brokerage Inc. He started in the Medicare business 11 years ago as an agent and as an agent manager with a large carrier. He now supports independent agents and agencies.
LaMonica Thomas is a licensed Medicare specialist. She has been in the Medicare business for nine years and is now a medicare broker which means she represents different Medicare insurance carriers in order to help her clients find the best plan for their needs.