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Michael T Braden August 28, 2024 FILING A MEDICARE CLAIM
HOW TO FILE A MEDICARE CLAIM
You may never need to file a Medicare Claim, but if you do we anted to provide you with steb-by-step Instuctions on how to file a Medicare Claim.
Medicare reimbursement may be necessary if you pay a claim out-of-pocket and should receive coverage through Medicare. While it is not common to need Medicare reimbursement, you still may find yourself in this situation. In this article we discuss filing a Medicare claim.
In most cases, your doctor or hospital will handle the Medicare billing process for you. But in a few situations, you may have to pay for your care upfront and file a claim, asking Medicare to reimburse you. The claims process is simple, but you will need an itemized receipt from your provider to proceed with the Medicare reimbursement process.
WHAT DOES MEDICARE REIMBURSEMENT MEAN?
If you receive your Healthcare Benefits from Original/Traditional Medicare, your doctors normally bill Medicare for any care you obtain. Medicare will then pay its portion directly to your doctor.
Then, your doctor will only charge you for any outstanding copay, deductible, or coinsurance. If you have a Medicare Supplement (Medigap) plan, your Medigap plan will cover their portion of your bill after Medicare pays their portion.
In a few cases, your physician might request for you to pay the total cost of your care upfront or via a bill. These situations include if your doctor does not participate in Medicare or if Medicare does not cover the service you receive. The doctor's office can assist you in filing a claim, but they are not required to do so.
If your doctor does not bill Medicare directly, you can file a claim asking Medicare to reimburse you for out-of-pocket costs.
NOTE: Even though your doctor may not accept Medicare, if you like her/him, you should keep them as your doctor. But, you could also suggest that it's okay if they assist you in speeding up the process by helping you to electronically file your reimbursement request from their office. Most doctors who do not accept Medicare Assignment can legally add 15% to the Maximum amount Medicare would pay for any specified service. And, if you have a Medicare Supplement Plan F or Plan G, your plan will pay the Excess Charge for you.
WHAT DOES THE MEDICARE REIMBURSEMENT PROCESS LOOK LIKE?
Original, or Traditional Medicare (Part A and Part B) allows you to see any doctor you choose. However, not all providers handle billing in the same way.
Medicare assignment provides a list of rates that Medicare will pay for the healthcare services it covers. If your provider participates in Medicare assignment, you will know your exact costs before you receive coverage.
Most doctors are participating providers that accept Medicare Assignment. They have agreed to accept Medicare’s rates as full payment for their services and will only bill you for the remaining deductible or coinsurance if necessary.
If you see a participating doctor, they handle Medicare billing, and you do not have to file any claim forms. However, some doctors don’t bill Medicare directly, so it is wise to speak with your doctor about their billing practices before receiving treatment. In this case, if you want Medicare to pay for your care, you must send a form requesting reimbursement.
WILL MEDICARE REIMBURSE ME IF I SEE A DOCTOR WHO DOES NOT ACCEPT MEDICARE ASSIGNMENTS?
A doctor who accepts Medicare patients but has not agreed to accept Medicare’s Assignment (Their Fee Schedule), is permitted to charge you, what is referred to as a Medicare Part B Excess Charge. This extra charge can be from 0-15%, and most often ends up being an additional 15%. So if your Doctor Visit would normally cost $300 using the Medicare rates, your doctor can add on 15%, or in this example, add on $45 so your $300 Office Visit is now $345. Medicare will reimburse you for 80% of the $300 amount, which would be $240, and send the balance of $60 for your Medigap/Medicare Supplement plan to pay, provided you have one. And, if you do have a Plan G or Plan F Medicare Supplement, they will send a reimbursement request to your Medicare Supplement company for the additional (15% Charge)
The extra fee is known as an excess charge. Non-participating doctors may bill Medicare directly. Alternatively, they may ask you to pay upfront and seek reimbursement from Medicare yourself if you qualify.
The best way to avoid these surprise charges is to verify that any doctor you see accepts Medicare.
REIMBURSEMENT FOR MEDICARE PART A (IN-PATIENT HOSPITAL CHARGES)
Medicare Part A is the Part of Medicare that pertains to care you receive as an IN-Patient at a Hospital, Skilled Nursing Facility (SNF), Hospice Care, and Home Healthcare.
Typically, your doctors will bill Medicare directly. In this case, you may need to pay a deductible or coinsurance. However, you may occasionally receive an unexpected bill from a doctor involved in your inpatient treatment. If this ever happens to you the easiest thing to do is for you to call Medicare at 1-800-MEDICARE. They will be glad to help you and give you all of the information and steps to submit your claim.
NOTE: A lot of times we cringe at the suggestion you need to call a 1-800 Number for Customer Service. However, I have personally never experienced this with calling 1-800-MEDICARE. They do an excellent job in teaching their Agents and Staff and they are truly there to assist you. They are patient and caring and there is no need to be irrational or curt when contacting them. And remember, if you are smiling while you are talking on the phone, you accomplish a lot more than you ever could with a sour look on your face.
REIMBURSEMENT UNDER MEDICARE PART B (OUTPATIENT SERVICES)
Doctor visits, durable medical equipment, and outpatient care fall under Medicare Part B. When making doctors’ appointments, always ask if the doctor accepts Medicare assignment; this helps you avoid having to seek reimbursement.
Be aware that some doctors have opted out of Medicare altogether, and Medicare will not pay for any portion of their services. Thus, ensuring your physician accepts Medicare before receiving services is essential.
If this happens, contact the doctor and find out if they accept Medicare assignments and if and when they plan to submit the claim to Medicare. using Form 1490S. https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1490s-english.pdf If they do not intend to submit the claim themselves on your behalf, request an itemized receipt so you can file a request for reimbursement.
WHAT IF YOU ARE COVERED UNDER MEDICARE ADVANTAGE (MEDICARE PART C)?
If you have a Medicare Advantage plan, you will never need to ask for reimbursement from Medicare. Medicare pays Medicare Advantage companies to process their claims independently.
Although you may need to ask your carrier to reimburse you for something, you will never have any cause to contact Medicare regarding reimbursement. You gave up your rights for Medicare to assist you once you agreed to join a Medicare Advantage plan. You may ask Medicare about pretty much anything else, but your plan has the final say on payments and reimbursements.
Your doctor can only charge you for your deductibles, co-payments, or co-insurance. Unless you go out of your "Network". If you see a physician out-of-network, there is a reasonable chance that you'll be responsible for up to 100% of the costs for an out-of-network provider.
Coverage for out-of-network doctors depends on your Medicare Advantage plan, and each plan is unique and has its own rules. Many Medicare Advantage HMO plans do not cover non-emergency out-of-network care. But, a Medicare Advantage PPO plan could provide you with some out-of-network coverage.
REIMBURSEMENTS FOR MEDICARE PART D
Medicare Part D is prescription drug coverage Medicare Beneficiaries receive from private insurance companies. These companies establish their own regulations and availability about which drugs they offer and what your cost will be for those medications.
As a general rule, pharmacies handle the insurance process, and you (The Medicare Beneficiary) will have to pay a Co-Insurance or Co-Pay amounts, for any medications you receive. Contact your prescription drug plan if the pharmacist tells you a drug is not covered or if the cost is higher than anticipated. Or, contact the Agent/Broker who sold you your policy and ask for their assistance. If you do not know who it was, and you need help, please feel free to contact us at www.bradenmedicare.com, send us a contact request, or just give us a call at (480) 225-1393 anytime.
WHERE CAN YOU FIND THE CORRECT FORM1940S TO SUBMIT?
Medicare Part D Reimbursement Form that you must fill out and return to Medicare. You can use this link to access and Print/Save the form, which is available in English and Spanish on the Medicare website.
SUBMITTING A BILL TO MEDICARE FOR REIMBURSEMENT OF WHAT YOU PAID FOR OUT-OF-POCKET
To receive reimbursement, you must send a completed claim form and an itemized bill supporting your claim. It includes detailed instructions for submitting your request.
You can fill it out on your computer and print it out or print it first and fill it out by hand. The form asks for information about you, your claim, and other health insurance you may have.
HERE IS WHAT MEDICARE REQUIRES TO HAVE ON ANY BILL SUBMITTED FOR REIMBURSEMENT:
DATE (When was the service provided/Appointment Date).
WHERE DID THE SERVICE TAKE PLACE (Address of the Doctors Office/Clinic, Hospital).
COST (How much were you charged for the service(s) you received?)
DEFINITION (Lists a description/reason for your visit, illness, injury, check-up, annual visit, etc.)
SUPPLIES (Lists any/all of the supplies and/or medications used for the procedure).
NAME, ADDRESS, AND TELEPHONE NUMBER (Of The Healthcare Professional you saw).
DOCTORS ID (List the National Provider Network Number (NPN) of the Doctor or Supplier you went to).
Send the CMS Form 1490s, along with any other documentation to the correct address for your state. (A listing of addresses is included in the link for teh CMS form 1490s.
FINDING DOCTORS WHO ACCEPT MEDICARE
To find a doctor that accepts Medicare, a person can visit the Medicare Physician Compare site and search by location, and by entering either:
Simply Type In the Last Name of the Healthcare Professional you are Considering.
Enter the Group Name or the Name Of The Practice, such as "Sunshine Family Healthcare".
Enter Their Specialty or PCP (Primary Care Provider) if they are not a "Specialist"
Enter your Medical Condition.