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Understanding Medicare Reimbursement & Claims

January 5, 2022

Understanding Medicare Reimbursement & Claims

When you use your Medicare coverage to get medical care, your doctor generally submits a claim for reimbursement to Medicare. Sometimes, you’ll need to do this yourself.

Understanding how Medicare reimbursement and claims work is an important part of using your Medicare benefits to their full advantage. This guide will help you understand what reimbursement is and in what situations you might need to take action.

What is Medicare Reimbursement?

In order for a doctor or medical provider to get paid by Original Medicare for providing services, the doctor’s office needs to submit a claim to Medicare. Usually, this is done automatically and you, as the patient, don’t need to do anything.

However, sometimes a doctor might not accept Original Medicare as payment. This could be because the amount Medicare agrees to pay is too low, or the paperwork is too difficult and frustrating. In this case, your doctor will either be non-participating or opt-out.

A non-participating doctor can charge you up to 15% more than what Medicare pays. You pay that amount upfront, and then file a reimbursement with Medicare to have them send you the approved payment amount. You file a reimbursement claim using form CMS-1490.

An opt-out doctor doesn’t accept Medicare payments and Medicare won’t reimburse you for care if you see them. As a result, you’ll pay the full amount yourself.

Keep in mind that Medicare Part C (Medicare Advantage) plans operate differently because they are issued from private insurance companies rather than managed by the Federal government like Original Medicare is.

Medicare Reimbursement Rates 2022

How much does Original Medicare pay doctors for specific services? The answer is based on a variety of factors. There’s a base rate that Medicare pays depending on the service provided. Then the base rate is adjusted based on the zip code, complexity of the patient’s health needs, and more.

When a doctor bills Medicare, they use a CPT billing code that represents the service they are billing for. There are thousands of different codes, each with its own reimbursement rate.

In order to get the Original Medicare-approved amounts for the care your doctor recommends, ask the provider what codes will be used and what the reimbursement amounts are for those codes.

Medicare Part A and B (Original Medicare) Reimbursement

If you have Original Medicare, you’ll use Medicare Part A for inpatient hospital stays and Medicare Part B for doctor’s visits and other medical needs.

How much is Medicare Part A reimbursement?

As we mentioned, it will vary significantly depending on the services you receive and the complexity of your case. Fortunately, your out-of-pocket cost does not change. After a deductible of $471, you’ll pay $0 for the first 60 days of hospitalization in the year, and then $371 per day for days 61-90 in the year.

For Medicare Part B reimbursement, again, it depends on your needs and the complexity of your healthcare. The Medicare Part B coinsurance is 20% of the Medicare-approved amount. That means it’s important to know how much the care will cost, so be sure to ask your provider.

Medicare Part C (Advantage) Reimbursement

Medicare Part C is a full replacement for Original Medicare and is provided by private insurance companies. When you have Medicare Part C, you never need to file a reimbursement with Medicare. Instead, contact the insurer if there are any concerns about claims or payments.

The important thing to remember about Medicare Part C plans is that most of them do not provide coverage for care that you receive outside the medical network. That means that if you see a doctor that doesn’t accept the coverage, you have to pay the full amount yourself.

Medicare Part D (Drug Coverage) Reimbursement

Generally, the pharmacy where you pick up your medication will take care of your Medicare Part D reimbursement filing. They will file directly with the plan to receive the payment they are due.

If you paid out-of-pocket for a medication that should have been covered, you’ll need to file a reimbursement claim with the Part D plan provider, not Medicare itself. Contact the insurer to find out what the process is.

Medicare Reimbursement Rules

In most cases, you won’t have to worry about the reimbursement rules because the provider or pharmacy will file the claim for you.

However, if you are filing for reimbursement from Original Medicare, you need to do so within 12 months of the service being provided. If you wait longer than that, you can no longer get payment from Medicare. You also need to send in a specific form, along with a copy of the itemized bill from the provider.

If you have Medicare Advantage, the rules may be different. You’ll need to contact your insurer to find out how to get reimbursement if your provider doesn’t file the claim.

Who is Eligible for Medicare Reimbursement?

To be eligible for reimbursement from Original Medicare, you either need to be a medical provider who has accepted the assignment or an individual with Medicare coverage.

For individuals, you can only ask for reimbursement for Medicare-covered services or services that are covered by your Medicare Advantage plan. In addition, the services need to be completed by a medical provider that is part of the plan — not an opt-out or out-of-network doctor.

As we’ve mentioned, it’s rare for a Medicare patient to need to get reimbursed from Medicare. In general, you’ll pay your copayment or coinsurance amount and the doctor will bill Medicare for the rest.

How Does Original Medicare Reimburse Physician Services?

There are a wide variety of CPT or HCPCS codes that apply to physician services. Each specific service has its own code, and the doctor’s office will use these codes when billing Medicare for your care.

If you receive a bill from the doctor that you did not expect, the first thing to do is contact the doctor’s office and ask them if they sent it through to Medicare with the right codes. Explain that you only pay your deductible and coinsurance or copayment amounts.

You can also call Medicare or your insurance provider directly to explain the situation. The goal is to get the billing corrected so you don’t pay more than you need to.

Have More Questions About Reimbursement and Claims?

Because there are thousands of service codes that can be billed to Medicare by your doctor, it’s hard to know exactly what the doctor will receive from Medicare. However, most of the time the only Medicare costs you need to worry about are your monthly premium, deductible, and copayment or coinsurance.

If you have more questions about Medicare reimbursement and claims, it might be helpful to talk to a licensed insurance agent. We can help you compare plans and answer any questions you have. Contact us today!

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