How To File A Medicare Claim

Braden Medicare Insurance
Aug 30, 2024
8 min read

Updated: Jan 6

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 want to provide you with step-by-step instructions on how to file a Medicare Claim in the event you ever need it.

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 how to file 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 to ask Medicare to reimburse you. The claims process is simple, but you will need an itemized receipt from your provider to proceed with Medicare reimbursement.

WHAT DOES MEDICARE REIMBURSEMENT MEAN?

If you receive your Healthcare Benefits from Original/Traditional Medicare, your doctors typically 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 its portion of your bill after Medicare pays its portion.

In a few cases, your physician might request that you pay the total cost of your care upfront or by bill. These situations include cases where your doctor does not participate in Medicare or where 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 if your doctor does not accept Medicare, you should keep them as your doctor if you prefer them. But, you could also suggest that it's okay if they assist you in speeding up the process by helping you to file your reimbursement request from their office electronically. 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 lists the rates Medicare will pay for covered healthcare services. If your provider participates in Medicare assignment, you will know your exact costs before coverage begins.

Most doctors are participating providers who 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 submit a reimbursement request form.

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 range from 0-15%, and most often amounts to an additional 15%. So if your Doctor Visit would generally cost $300 under Medicare rates, your doctor can add 15%, or in this example, add $45, so your $300 Office Visit is now $345. Medicare will reimburse you for 80% of the $300, which is $240, and you will be responsible for the remaining $60 for your Medigap/Medicare Supplement plan, 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 inpatient 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 a coinsurance amount. 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 to call Medicare at 1-800-MEDICARE. They will be glad to help you and provide all the information and steps to submit your claim.

NOTE: We often cringe at the suggestion that you need to call a 1-800 Number for Customer Service. However, I have personally never experienced this when calling 1-800-MEDICARE. They do an excellent job of training their Agents and Staff, and they are genuinely 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 scheduling doctor appointments, always ask whether 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 to confirm whether they accept Medicare assignments 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 need to contact Medicare for reimbursement. You gave up your Medicare rights to receive coverage 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 deductible, copayment, or coinsurance. 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 that Medicare Beneficiaries receive from private insurance companies. These companies set their own policies and availability for which drugs they offer and the cost of 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 amount 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 request 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 give us a call at (480) 225-1393 anytime.

WHERE CAN YOU FIND THE CORRECT FORM 1940S 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 or 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 doctor's 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 (List 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 list of addresses is included in the link to the 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:

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.

The search results will then list every Doctor in your location who accepts Medicare within the field you specified.

QUESTIONS SPECIFIC TO MEDICARE REIMBURSEMENT

HOW LONG IS THE PROCESS TO RECEIVE A REIMBURSEMENT FROM MEDICARE?

It usually will take Medicare about Sixty (60) days to process a reimbursement claim. Most people filing a claim have already paid their Doctor's bill out-of-pocket, but if you have not done this, please reach out to the doctor's office, let them know you are submitting a claim, and that the process may take two months to resolve. Any doctor can submit a claim on your behalf, and if they refuse, citing that it takes too much of their time, don't worry about how long it takes. You might also consider interviewing other doctors who accept Medicare or will submit a claim on your behalf.

HOW LONG WILL THE DOCTOR HAVE TO WAIT TO GET PAID IF YOU HAVE NOT PAID THEM YET?

Once your service is approved, Medicare claims to providers take about 30 days to process. The provider usually gets direct payment from Medicare. Otherwise, if you have already paid your doctor, Medicare will send a check directly to you.

WHAT THE HECK IS A MEDICARE FEE SCHEDULE?

The Medicare Fee Schedule is the amount Medicare will pay for each procedure and service, for Doctors, Hospitals, Ambulances, Transportation, etc., as listed in its Medicare database. So if an Office Visit fee is $300, that is the maximum amount any Doctor who accepts Medicare can charge for an Office Visit. If you see a Doctor who has not agreed to the Medicare Fee Schedule (AKA Medicare Assignment), they can charge you an amount up to 15% more than Medicare. However, if you have purchased a Medigap or Medicare Supplement Plan G or Plan F policy, your Supplemental Insurance Company will pay his additional fee for you.

WRAPPING THINGS UP

Did you know there are over 1 Million Licensed Doctors in the United States?. The majority of doctors who do not accept Medicare are Pediatricians, Psychologists, and Psychiatrists. All told, nearly 94.7% of all physicians accept Medicare in the United States of America.

We love to hear from Clients and Non-Clients alike. If you would like to reach us, please email us directly at mike@bradenmedicare.comor call us anytime at (480) 225-1393.