We get asked all the time, “Will Medicare cover my procedure (surgery, lab-test, injection, prescription…)?” We wish that the answers could be as simple as yes or no.
Unfortunately, the answer to this question isn’t always as cut and dry of an answer as you’d like.
Yes, Medicare states what they do and don’t cover, but there are other correlating factors that go into a service or procedure being covered.
Factors like the procedure’s medical necessity, the doctor’s participation, and how the bill is coded are some variables that affect the answer to this question. Continue reading to see what we mean.
Medical Necessity of a Procedure
Medicare’s definition of medically necessary is this, “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
Based on this definition alone, you may be able to answer your question right off the bat. For instance, if you’re asking, “Will Medicare cover my facelift?” based on the above information, no. However, there are a few circumstances where your doctor can request a procedure to be covered even if it isn’t thought of as medically necessary at first.
For example, Botox injections normally aren’t covered because they usually aren’t medically necessary. However, your doctor could submit documentation stating that the injections are medically necessary to treat specific conditions such as migraines.
If your procedure qualifies as medically necessary, then you can move on to the next step.
Your Doctor’s Participation in Medicare
For your procedure to be covered, you must make sure that you are seeing a doctor that accepts Medicare.
Your doctor needs to accept Medicare in order for your procedure to be coverage. He also needs to accept Medicare assignment in order for you to not have to pay excess charges. Excess charges are an up to 15% charge that the doctor can tack onto your bill if he or she doesn’t accept Medicare’s approved prices for services and procedures.
Fortunately, if you see a doctor that doesn’t accept Medicare assignment and you have a Medigap plan like Plan G, then you won’t have to worry about paying those excess charges since your Medigap plan will cover them.
There are also a few states where excess charges are not allowed.
It’s best to see doctors that don’t charge you more than you have to pay. However, if you have a doctor that you love that charges excess charges, consider Medigap. If you have a Medigap plan that covers these charges for you, you’re in great shape.
The Medical Coding of the Bill
Every service, procedure, prescription, and doctor visit have a code that corresponds with it. This code is how the doctor’s office, the billing department, and the insurance company communicate with each other. The code indicates what happened during the visit. Everything is coded down to the littlest detail like the patient’s symptoms.
A medical bill may have multiple codes detailing how the services and procedures should be charged. If the wrong code is chosen for the type of visit, Medicare could deny the bill. Medicare would then return it to the doctor’s office for you to pay in full.
Let’s look at the “Welcome to Medicare” visit. This is a doctor visit that you can obtain within your first 12 months of being on Medicare. If coded correctly, this visit is 100% covered by Medicare Part B.
However, if the medical coder doesn’t use the right code for this visit, Medicare will not cover it since the translation of the service provided was incorrect. This is one of the most common issues that our Client Service Team deals with and resolves on a daily basis. We resolve extremely common billing hassles like this for our policyholders and this service is completely free.
Cover Your Bases
As you can tell, there are many aspects that must come together in order for a service or procedure to be properly covered. There is no cap to how much Medicare will pay out for any medically necessary service. As long as the service continues to be medically necessary and the other requirements are met, then Medicare will continue to pay.
There are a few things you can do to make sure you get the coverage you should.
First, using The Center of Medicare and Medicaid Services’ Whats Covered app, check to see if Medicare covers your procedure in general. Then, check with your doctor to make sure he or she accepts Medicare and accepts assignment.
Finally, you will want to make sure the medical coder codes the bill correctly. Of course, you can’t look over their shoulder and check their work. Just don’t be afraid to ask your doctor to verify with the billing department before sending it to Medicare.
Not all doctor’s offices are well-versed in Medicare coding, and that’s okay. That’s why we are here to back you up and fix these issues as they arise. If you have your policy through Boomer Benefits and you recently received a bill that you aren’t sure if you are supposed to pay it or not, contact our Client Service Team today at 817-249-8600.