Medicare Reimbursements: What Medical Services Qualify? | GoMedigap

Medicare Reimbursements: What Medical Services Qualify?

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Medicare Reimbursement

Medicare reimbursements are payments that physicians and hospitals receive as compensation for rendered services to Medicare beneficiaries. Medicare sets the reimbursement rate for each service. However, these rates are typically lower than the amount that a private insurance company would pay. It is also typically lower than the total amount billed.

In most cases, you won’t have to submit Medicare reimbursement claims to get reimbursement. This is because you typically don’t pay upfront for health care services. Usually, you make cost-sharing payments such as coinsurance and deductibles. The following article will outline the process of acquiring Medicare reimbursement if necessary. It will also list several services that can warrant a reimbursement, and provide other helpful information.

Filing a Medicare Claim for Reimbursement

Your health care provider is typically responsible for filing a Medicare reimbursement claim. However, to cover the cost of each health care service, you may have to fill out a Medicare claim yourself. You would need to do this to receive Medicare reimbursement. As long as Medicare covers the provided health care service, you can file a claim for reimbursement for that service.

  • Claims for Medicare Part A and Part B

With an Original Medicare plan, which includes Part A for hospital coverage and Part B for medical coverage, you will need to file a Medicare reimbursement claim only if your doctor has delayed filing and you have failed to get the claim filed through other means. This is an uncommon situation, but it’s always useful to be prepared.

  • Claims for Medicare Part C and D

There are no Medicare claims with Medicare Part C (Medicare Advantage Plans) and Part D (prescription drug coverage). This is because Medicare pays a set amount each month to the health insurance plan they contracted with to perform medical services. However, patients with these programs are still responsible for cost-sharing established by the Medicare Advantage or Prescription Drug plan. These payments might include copayments, coinsurance, and deductibles. If you are seeing a doctor outside of your network who accepts Medicare, you will likely have to file the claim yourself.

  • Time Limits

You can’t file a Medicare reimbursement claim any later than 12 months after the service date. For example, if you received health care services on June 15, 2019, your doctor has until June 15, 2020 to file the claim. Even if the reimbursement is not coming directly to you, you will want to follow up on the claim to make sure it was filed. If you have any questions about this process or are experiencing any difficulty, you can call 1-800-MEDICARE (1-800-633-4227). This will direct you to speak to a Medicare representative 24 hours a day, seven days a week.

  • Medicare Forms

You can access Medicare forms on the Center for Medicare and Medicaid Services website. Search for CMS 1490S, Patient’s Request for Medical Payment, then download and print this form. Forms are also available at your local Social Security office. Remember that you can always call the Medicare hotline for assistance filling out and mailing this form.

Finding a Doctor Who Accepts Medicare

A Kaiser Family Foundation analysis found that 93 percent of non-pediatric primary care physicians were participating providers with Medicare in 2015, though only 72 percent were accepting new Medicare patients. Health care professionals who agree to fully accept the rates set by Medicare are called participating providers. These physicians will accept reimbursements for all Medicare-covered services and patients, and bill Medicare directly for these covered services. Medicare.gov even has a convenient search tool that patients can use to find out if your doctor of choice is a participating provider.

Some physicians choose not to be participating providers because the reimbursement rates they receive from Medicare are often lower than what they receive from private insurance carriers. However, even non-participating providers can agree to accept Medicare reimbursement for certain procedures. In these cases, you may have to cover the cost of the bill upfront and then seek reimbursement from Medicare for a portion. The provider is paid 95 percent of the fee schedule amount, and can only bill you up to 15 percent more than the Medicare reimbursement amount. Some states limit this even further. For example, New York caps the amount at just 5 percent.

Because it’s so rare, the prospect of filing a Medicare reimbursement claim might seem a little intimidating at first. Fortunately, Medicare makes it easy for patients to research and ask questions regarding their coverage and take matters into their own hands when necessary. For additional assistance and advice, don’t hesitate to contact a licensed agent at our site.

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