If dealing directly with insurance companies sounds like your worst nightmare, you’re in luck with Medicare. That’s because, in the vast majority of cases, your doctor or other health provider takes care of filing all Medicare claims for you. There is usually not a need for a Medicare reimbursement.
Providers who accept assignment bill Medicare directly for their services. Medicare pays them directly for the allowable charges according to standard reimbursement rates. Then the provider bills you for the difference, and for any services not covered by Medicare or your Medigap plan, if you have one.
If you have Original Medicare, your provider should give you an Advance Beneficiary Notice of Non-coverage if Medicare doesn’t normally pay for a service your doctor recommends. You have the option of having the service done and possibly paying for it upfront (your doctor will still bill Medicare even if the claim will likely be denied). You also have the option to refuse service.
Keep in mind, even if the claim is denied by Medicare, you do have the right to file an appeal.
How does Medicare assignment work?
Providers who “accept assignment” have signed an agreement with Medicare to accept Medicare reimbursement rates. This means that even if they would normally charge more for a service than Medicare pays, they will consider Medicare’s allowable rate as payment in full for that service. They can only collect your coinsurance amount based on those rates.
Here’s how it works:
Your doctor refers you for a chest x-ray at the imaging center. The center’s normal cost for a chest x-ray is $80. Because they accept assignment, however, they can only charge Medicare’s allowable amount for a chest x-ray, or $30, for example.
They can’t bill you the $50 difference between their normal prices and Medicare’s rates. Now, you still owe your Part B coinsurance of 20%, which would $6 (or 20% of $30, the allowable amount under Medicare.)
Of course, you need to meet your annual deductible before Medicare pays, unless you have a Medigap plan with first-dollar coverage that pays your deductible. Your copayment amount may also be different if you are enrolled in a Medicare Advantage plan. Check the plan’s Summary of Benefits to find out what your cost-sharing is for the service you are receiving.
When would I need to file a claim for Medicare reimbursement?
There may be times when you are treated by a provider that doesn’t accept Medicare assignment. In this scenario, you may have to file a claim for Medicare reimbursement yourself.
Providers that don’t accept Medicare can charge you more for the service than Medicare allows, but under federal law, they can only charge 15% more than Medicare’s allowable rate. This is called an excess charge.
For example, if Medicare pays $100 for a service, and the provider normally charges $250 for it, he can still only bill you $115. Your provider may ask you to pay for your care upfront since he doesn’t accept assignment.
If you need to file a claim for Medicare reimbursement, here are the steps you should take:
- Complete a Medicare form 1490s, “Patient’s Request for Medical Payment.”
- Attach an itemized bill from the provider including the following information: the date and place of service (doctor’s office or hospital, for example), the description and charge for each service, your diagnosis, and the name and address of the provider who cared for you.
- Send the form and the itemized bill to your local Medicare contractor. You can find your local contractor using the interactive map on the Centers for Medicare and Medicaid Services website.
If you have other insurance besides Medicare, you’ll need to detail that information on Form 1490s. There is a time limit on filing claims with Medicare. Generally speaking, you need to submit your information within one calendar year of receiving care.
If you have questions about the form, or problems finding your local Medicare contractor, you can always visit the Medicare website or call 1-800-MEDICARE for help.
What about Medicare Advantage and Part D plans?
If you have a Part D plan or are enrolled in Medicare Advantage, the steps for submitting claims are a bit different. This is because Part D and Medicare Advantage are actually administered by private insurance companies that contract with Medicare. Each plan has its own rules for paying claims.
You should contact your plan directly if you get care from a provider outside your plan’s network. In most cases, unless you need emergency care, you must follow the plan’s rules for using network providers. You may have to pay 100% of the costs for your care if you don’t.
Keep in mind, you still have all the rights and protections under the Medicare program if you enrolled in Medicare Advantage or a Part D prescription drug plan. If you feel your plan has treated you unfairly, you can contact your local Medicare ombudsman for help.
Get Someone on your Side with Medicare
Did you know that if you enroll in your Medigap policy through Boomer Benefits, we provide free claims support? That means you would have us to guide you through filing any claims for Medicare reimbursement. Give us a call today to find a Medicare plan that is just right for you.