Your Guide to Understanding Providers, Claims, and Appeals for Medicare Recipients

Sometimes, when trying to understand medicare providers, claims, and appeals, you might feel as if you need a magic wand, a Rubix cube, a decoder ring, and a sorting hat to achieve your goals, but it’s not as complex as that if you take it step by step.

Participating, Non-participating, and Opt-out Providers

Participating, Non-participating, and opt-out providers can be a sticky wicket to figure out. But if you pay close attention and ask your health provider important questions, you will end up paying reasonable amounts. Before you set an appointment, it is important to ask your provider if they are a participating provider, non-participating provider or an opt-out provider. You may decide to seek services elsewhere or be willing to pay out of pocket for the service. If you have Original Medicare, then your Part B cost will vary after you have met your deductible.

There are three different kinds of providers that vary depending on their relationship to Medicare Part A. This will then determine how much you will pay for Part B-covered services.

Participating providers

Participating providers accept Medicare and always take an assignment.

This means

  • They accept the amount that Medicare pays for the services.
  • They submit a bill and Medicare pays them directly.
  • You are responsible for 20% of the bill, which is your co-pay.
  • Certain kinds of providers (clinical social workers and physician assistants) are required to take an assignment if they accept Medicare.

Non-participating providers

Non-participating providers accept Medicare

  • They agree to take assignments on a case-by-case basis.
  • They do not accept Medicare’s approved amount as full payment.
  • The charges are different. You are responsible for up to 35%, which constitutes a 20% coinsurance + 15% limiting charge that reflects Medicare’s approved amount. This is only for covered services.
  • If you pay the full charge upfront, your provider should submit a bill for an 80% reimbursement.
  • The limiting charge rules don’t apply to any durable medical equipment suppliers.

Opt-out providers

Opt-out providers are the Wild West of medical expenses, and you need to look at a detailed contract first to know what your payments will be. They don’t accept Medicare at all. In fact, they have signed an agreement to be excluded from the Medicare program.

The most common opt-out caregivers are psychiatrists.

If your provider is an opt-out provider, Medicare won’t pay for any claims.

  • You would then be responsible for the entire cost of your care.
  • You will receive a private contract describing their charges. Additionally, the contract confirms that you are responsible for the full cost of your care, and Medicare will not reimburse you, nor pay your provider.
  • They will not bill Medicare for any services you receive

Choosing the correct type of provider can help prevent future headaches. However, there can still be issues arise from time to time with your claims, even if you are careful in advance. Read on about how to navigate any issues you may experience with claims.

Your provider Refuses to File the Claim

One of the worst situations is when your provider refuses to file a claim. There could be a number of reasons. The most common are

  • the provider doesn’t believe the claim will be honored and paid,
  • they feel you should pay full price, or
  • they have opted out of Medicare.

In order to expedite filing a claim, here are some things you may do.

  • Your provider thinks that coverage will be denied.
    • an Advance Beneficiary Notice or an ABN will need to be signed before giving services and your provider must ask you to do this.
    • Before you sign an ABN, ask if your provider thinks that the service needs to be done, and is medically necessary.
    • Ask if they will help you appeal if it’s not covered.
    • Request that your provider file a claim with Medicare, even if they feel coverage will be denied.
    • You may be within your rights to appeal when coverage is denied.
  • Your provider asks that you pay for your services in full.
    • If your provider is a participating provider, request that they submit the claim to Medicare. If they refuse you may contact the state medical licensing board to report this.
    • If your provider is a non-particpating provider, they may request payment from you upfront at the time of service.
    • However, by asking your provider to file a claim with Medicare on your behalf, you may receive Medicare reimbursement for 80% of the Medicare-approved amount.
  • When your provider has opted out of Medicare, you must accept that you will pay full cost.
    • They must have signed an agreement to be excluded from the Medicare program.
    • They do not bill Medicare for services.
    • You may not submit a reimbursement form to Medicare.
    • Will will be subject to paying the entire cost of the care you received.
  • If your provider refuses to bill Medicare and does not specify why in writing, then:
    • It is considered Medicare fraud
    • It should be reported.
    • To report fraud, contact 1-800-MEDICARE,(877-808-2468), or the Inspector General’s fraud hotline at 800-HHS-TIPS. or the Medicare Administrative Contractor, To find the MAC in your area, call 1-800-MEDICARE.

Advance Beneficiary Notice (ABN)

An Advance Beneficiary Notice (ABN) is a medical Medicare waiver of liability. It is more than that though. An ABN alerts you to make a decision on receiving the care or not and that you are accepting financial responsibility for the service if Medicare denies payment.
The important thing to look for is that the notice absolutely must list the precise explanation that the provider thinks that Medicare will not approve payment of the claim. One such example of this would be that Medicare pays for a particular test one time every four years” or “Medicare doesn’t pay for this particular test or service.”

An older gentleman wanted his physician to check his Vitamin D and B12 levels and was informed they were an out of pocket expense. To which he replied, “If we can figure out why I’m tired and help me feel better, it’s worth it.”

Know why you might get a service or test, and how it can affect your health and well being.

If a service or item is not ever covered by Medicare, providers do not need to give an ABN. It’s up to you to read about this and determine if it’s not covered. For example, hearing aids, a common item, is not covered.

Now, this is where it gets complex. The ABN is meant as a warning that Medicare may not pay. However, it is often possible that Medicare will pay. In order to get an official decision from Medicare, you must take a number of steps. All of these steps must be done

  • You must first sign the ABN.
  • You must agree to pay if Medicare does not.
  • You must receive the care.
  • You must request that your provider bills Medicare for the service before billing you.

Medicare Summary Notice (MSN)

The Medicare Summary Notice is known as an MSN

  • is mailed four times a year
  • is not a bill
  • summarizes the care and items that various providers have provided you in the previous three months.
  • You will receive the MSN from the contractor that has processed your claims for Medicare, so you may notice the name and address of an unfamilar company on it.
  • it contains information about
    • charges billed to Medicare,
    • the amount that Medicare paid,
    • the amount you are responsible for
  • Additionally
    • If you have paid a bill but receive reimbursement for it, you may receive an additional MSN.
    • If you do not receive health care services during a particular quarter, you won’t get an MSN.
    • If you are expecting an MSN because you have received services during a quarter, but have not gotten one, you can call Medicare or view your MSN online.
    • You may still request a paper copy for your records.

Original Medicare Standard Appeals

Original Medicare is managed by the federal government. It provides Medicare-eligible individuals with coverage for and access to doctors, hospitals, or other health care providers who accept Medicare.

You should know which plan you have, either Orginal Medicare or a Medicare Advantage plan. You may do this by checking your enrollment status.

If you go for an appeal, you must follow the chain of command, even a first denial can be bumped up to the next level, but you must be critically aware of the dates and time limits.

When you view your enrollment status, you will see

  • the name of your plan,
  • what type of coverage you have,
  • the length you have had your plan.

You can check your status online at www.mymedicare.gov or call Medicare at 1-800-633-4227.

A standard appeal is when you are questioning whether or not care should have been covered.

When your health service or item was denied, you have the right to appeal. An appeal is an official request when you disagree with a payment decision or coverage of a service or item.

However the most important thing you must do is sign an Advance Beneficiary Notice (ABN).

And before appealing,

  • make sure that Medicare was billed
  • that you received a formal written denial

You may start an appeal by following the instructions that are listen on your MSN or on a Redetermination Request Form.

  • Fill in the Redetermination Request Form
  • Submit this form to the Medicare Administrative Contractor or MAC within 120 days of the date on your MSN.

These steps will start your appeal and MAC should make a decision within 60 days.  If during this time you receive a bill for the service, contact your provider’s billing office to inform them that you have filed an appeal.

Success or Denial

  • Your appeal may be approved in which care the service or item will be covered.
  • Your appeal may be denied. In this care you can move up to the next level of appeal by contacting the Qualified Independent Contractor (QIC) within 180 days of the date listed on the MAC denial letter.
  • You should hear from the QIC within 60 days for a decision.
  • If your appeal at the QIC level is approved you will receive coverage for the service or item.
  • If the appeal has been denied again, the service or item must be worth at least $160 to proceed. You may move up the ladder of appeals with the Office of Medicare Hearings and Appeals (OMHA)
  • This appeal is required be filed within 60 days of the date on your QIC denial letter.
  • A lawyer or legal assistance from an organization may be utilized once you are appealing at the OMHA level, but it is not required.
  • The OMHA makes a decicion within 90 days.
  • If the OMHA approves your appeal, your service or item will be covered.
  • If the appeal is again denied, you may submit an appeal to the Council within 60 days from the denial by OMHA, as noted on their notice to you.
  • The Council is under no requirement to make a desicion within a particular timeframe.
  • If the Council approved the claim, it will be paid.
  • If it is denied at this level, your claim but be worth at least $1,630 to continue. At this point, the Federal District court would be the next step. You must submit the appeal to them within 60 days of the denial by the Council, as noted on the letter.
  • The Federal District Court may make a decision within any timeframe. There is no limit.

Knowing what you need to do each step of the way, can make your journey smoother.

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