Dear Toni:
I am just so confused with Medicare because I have a bill with a new doctor and Medicare says they will not pay? I never had this type of problem when I worked and was on a company plan. Can you please tell me what to do? I really do not know who I should call or what to say? I recently turned 65 and enrolled in Medicare and a Medicare supplement in December 2012. Boy what a mess!! This is too much for me. I need some advice…Thanks, Jane from Houston, TX.
Hello Jane:
I rarely see a problem with doctor’s/provider’s bills, but when it does happen, there is a process you must do to find out if the office visit or procedure will be paid as a Medicare approved service.
If Original Medicare will not pay for care you received, you will find this out when you receive your Medicare Summary Notice (MSN). The MSN is a summary of claims for health care services Medicare processed for you during the previous three months. The MSN is not a bill. Medicare Summary Notices (MSNs) are mailed four times a year and contain information about submitted charges, the amount that Medicare paid, and the amount you are responsible for. MSNs are used only with “Original Medicare” and not with a Medicare Advantage Plan. If you think the care you received is medically necessary, you should not take no for an answer!!
Here is what you should do if you believe the claim is medically necessary:
- Find out if it is possible that there was a billing mistake. Medicare uses a set of service codes, called CPT codes, for processing medical claims. Each medical service has been assigned a specific code. Sometimes providers accidentally use the wrong codes when filling out Medicare paperwork, and this can result in Medicare denials. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct codes. Your doctor’s billing office can call 800-MEDICARE to get in touch with the company that processes Medicare claims if the wrong code was used, ask your doctor to resubmit the claim with the correct code.
- If the provider believes that the claim was correctly coded or is unwilling to refile the claim, your next step is to appeal. Appealing is easy and many people win! The MSN will have instructions for how to appeal. Follow these instructions or call 1/800-MEDICARE for help. If the MSN lists several items and you are not disputing all of them, circle the one you want to appeal. Write “Please Review” on the bottom and sign the back. Make a copy for your files. Then mail the signed original to Medicare at the address on the MSN. Make sure you mail your appeal within 120 days of receiving the MSN.
- If possible, get a letter from your health care provider saying that you needed the service and why. Send this with your MSN.
Always keep photocopies and records of all communication, whether written or oral, with Medicare concerning your denial. Send your appeal certified mail and make sure you ask the post office or UPS for a signed delivery confirmation.
This may take time, so be patient to get a final answer! If you have any other questions about this subject email me at toni@tonisays.com.
Toni King, author of the Medicare Survival Guide which is on sale at www.tonisays.com. Toni is an advocate/consultant for those “Confused about Medicare”. Email questions to toni@tonisays.com or call 832/519-TONI (8664). Listen to Toni and her guests talking about the Confusion of Medicare at 11:00 AM each Saturday for the Medicare Survival Guide Hour on 100.7 FM KKHT “The Word” and 1070 AM “The Answer”. If you miss listening to the radio show all recording are available at www.tonisays.com.
