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Medicare Reimbursement

Except in rare cases, your Medicare claims will be sent directly from your Medicare providers to Medicare. Payments will then be sent directly from Medicare to your Medicare providers according to the Medicare reimbursement rates. This is often accomplished electronically. Only in very unusual circumstances will Medicare reimburse a Medicare patient directly for expenses related to his or her medical care.
How Medicare reimbursement rates work
Medicare reimbursements do not apply to Medicare deductibles or Medicare premiums. They only apply to charges directly related to medical care. Medicare reimbursement rates are set by federal legislation and govern how much a provider or supplier will receive from Medicare to provide a given medical service or supply.

If you have Original Medicare, Part A and Part B, your Medicare providers and medical suppliers are required by law to submit Medicare claims related to your medical care directly to Medicare. These claims are often filed electronically, and payment is made according to the Medicare reimbursement rates listed in the Medicare fee schedule.

If you have a Medicare Advantage plan, your plan provider does not have to file a Medicare claim because Medicare pays the insurance company a set amount each month toward your medical expenses. Your doctor or supplier would then file a claim directly with your plan provider. Different Medicare Advantage plans have slightly different Medicare reimbursement rates for the same services. This partly explains how some Medicare Advantage plans can have more in-network providers than other plans in the same area. Doctors may choose to accept the plans that offer higher payments.
When you need to file a Medicare claim
In rare cases, you may have to file a claim for reimbursement. This would only happen if you received services from a provider that did not accept Medicare assignment.

How assignment works: If a provider accepts Medicare assignment, it means the provider is a participating contractor with Medicare and has agreed to accept the Medicare-approved reimbursement rates as full payment for a medical service or supply. This means that if the approved Medicare reimbursement rate for a mammogram is $100, then a provider that accepts assignment will be required to accept $100 as payment in full for the service, even if his or her normal billing rate is $115. You would still be responsible for your portion of the fee (usually determined by your copayment or coinsurance, if your yearly deductible has already been met). However, because the provider accepts payment according to the Medicare reimbursement rates, you cannot be charged for the extra $15 not paid by Medicare.

If you received medical care from a provider that did not accept Medicare assignment, you may be required to pay for the entire service up front. If this was the case, you may need to file a claim for reimbursement. Your claim will be governed according to the Medicare reimbursement rates, even if your bill from the provider was more than the approved Medicare amount. Non-participating providers can charge Medicare patients up to 15% above the Medicare-approved amount.
How to file a claim
If you do need to file a Medicare claim, you will have to complete a “Patient’s Request for Medical Payment” form and send the completed form, along with an itemized bill from your provider, to the Medicare contractor for your state. To look up your state’s Medicare contractor, visit CMS.gov or contact Medicare.

You will be required to describe the reasons why you received medical care from the medical provider on the request form and to specify whether the illness or injury is related to a work incident. You will need to include information about any other insurance you may have, including insurance coverage through your employer or through your spouse’s employer.

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The itemized bill must list the following information:

  • The date of service
  • The place of service (doctor’s office, hospital, patient’s home, etc.)
  • Description of each surgical or medical service or supply furnished
  • Charge for each service
  • Name and address of the doctor or supplier who provided the service to you
  • Diagnosis (unless you have supplied a good description of your illness on the form itself)

 

For help filing Medicare claims, visit the Medicare.gov website.

There are time limits for filing Medicare claims. If you’re filing a Medicare claim as a beneficiary, you must submit your claim within one calendar year of the date that the service was provided. Any claims submitted more than a year after the service was provided will likely be denied.
Medicare Advantage and Medicare Part D claims
Medicare Advantage and Medicare Part D plans do not file claims directly with Medicare. If you are enrolled in a Medicare Advantage plan or a Medicare prescription drug plan, you may be required to pay the full cost for any services you receive from providers that are outside of the plan’s network. If you have questions about Medicare reimbursement rates or costs, and you are enrolled in a Medicare Advantage or Medicare Part D plan, you should contact your plan directly.

I’m always happy to answer your questions about how Medicare works or help you find a Medicare plan. Learn more about me by clicking on the orange button below my photo. Or, use the link below to schedule a phone appointment or have me email you with more information. You can also compare plans on your own by using the Find Your Plan button–it’s the blue one on the right side of this page. Or, for help right away, just contact me or one of my helpful colleagues at eHealth by calling 1-844-847-2659 (TTY users, please call 711).

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