Medicare Billing Errors

Victoria Burke by Victoria Burke | Licensed since 2011
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This article was updated on: 09/06/2017

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If you or a loved one are covered by Medicare, you can find a lot of information on Medicare.gov about how much you can expect to pay for various medical services. For example, if Medicare covers 80% for an item of durable medical equipment, you can generally expect a bill for 20% of the Medicare-approved amount. If you receive a bill for 50% or 100%, there may have been a Medicare billing error. Billing errors can occur accidentally or they can be intentional incidents of fraud or abuse.

What to do if you suspect a Medicare billing error

If you receive a bill and experience what you believe to be a Medicare billing error, the first step is to contact your insurance carrier’s customer service department. Do this to verify that the billing error exists. The customer service representative may be able to explain the bill and confirm that there is no error. Keep in mind that Original Medicare, Medicare Advantage, Medicare Supplement and Medicare prescription drug plans all have limits on what they cover. For example, Medicare Part D Prescription Drug Plans generally don’t cover prescription drugs for erectile dysfunction or weight loss and you will typically be responsible for 100% of the cost of these prescription medications.

If you verify that there is an error, you then want to find out how it occurred. Your carrier’s customer service department can usually assist you with this question. Human error might result in mistakes, such as incorrect coding. Fraud and abuse are more serious. According to the Centers for Medicare and Medicaid Services (CMS), examples of Medicare fraud can include knowingly:

  • Billing Medicare for medical appointments the patient did not keep
  • Billing for more complicated services than the services actually provided
  • Billing for services or supplies that were not provided

According to CMS, examples of Medicare abuse could be:

  • Billing for unnecessary medical services
  • Charging too much for services or supplies
  • Misusing codes, such as “upcoding”

Fraud and abuse are legal and could entail criminal and civil liability. If you suspect fraud, you can report it to the Medicare Fraud and Abuse at 1-800-447-8477 or TTY 1-877-486-2048. Hours Are 7 AM to 8 PM Mon-Fri, EST.

If the error is a human error and not fraud, work with the carrier to rectify the error. If the insurance carrier is not finding a satisfactory solution, you may contact Medicare at 1-800-MEDICAR (800-633-4227) TTY: 877-486-2048 Open 24 hours, 7 days a week. Medicare personnel can help you address billing issues related to Medicare Part D, Medicare Advantage plansMedicare Supplement plans, and Original Medicare, Part A and Part B.

Your state’s Department of Insurance can offer additional assistance with Medigap plans.

Now that you know more about handling Medicare billing issues, you may have other questions about private Medicare insurance. I’m always happy to help people get the answers they need. If you’d like to start by getting more information in front of you, use the other links down there to either schedule a phone appointment or request an email with more information about plans. To view all available Medicare plans available in your area, use the blue Find Your Plan button on the right side of this page. Or, if you need assistance right away, just call us at 1-844-847-2660 (or 711, for TTY users). Representatives are available 8AM – 8PM Eastern Time Monday through Friday.

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