Can I know the cost of a medical service in advance?

Pamela Cannaday by Pamela Cannaday | Licensed since 2011
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This article was updated on: 10/06/2018

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The cost of medical care can have a significant—and unwelcomed—impact on your budget. While managing your health and the cost of care can be challenging, the good news is that Medicare will help pay some of the cost for covered medical care. In addition, you can estimate your out-of-pocket expenses before you receive medical care by following a few steps described below.

What medical service(s) will you receive?

Are you scheduling a routine preventive exam with your doctor? Did your doctor order tests, a procedure, or a referral to a specialist to diagnose or treat a medical condition? Or do you have a planned hospital admission for a procedure or test? Your cost depend, in part, on the type of care you receive.

Medicare Part B covers a number of preventive services at no cost to you. For some of these preventive services and screenings, you generally pay nothing for the test as long as the doctor participates in Medicare. These include:

  • A “Welcome to Medicare” preventive visit available during the first 12 months you have Medicare Part B
  • An annual wellness visit
  • An annual screening mammogram
  • A screening colonoscopy
  • An annual Prostate specific antigen (PSA) test
  • Annual flu shots, vaccines to prevent pneumococcal infections such as pneumonia, and shots for hepatitis B (for those at high or medium risk)
  • A yearly visit with your primary care provider to help you lower your risk for cardiovascular disease.

To learn more about your coverage for each type of service and screening, you may refer to the Medicare handbook, Medicare & You.

When it comes to diagnostic care and treatment, determining the cost of proposed care gets more complicated. Prices can vary for the same test or procedure across the country and even within a particular metropolitan area. Furthermore, even your health-care providers do not know precisely what services you may need during or after a procedure. Don’t be discouraged. You can still obtain an estimate about the cost of your planned care.

  1. Ask the experts the cost of proposed medical services
  1. Talk to your doctor about the proposed treatment. Ask for a list of medical services associated with the treatment and their estimated cost. Find out if the treatment will be performed in the office, in a hospital setting, or in an outpatient facility. Where you receive treatment often determines how much you will pay.
  2. Contact your Medicare plan customer service to verify whether the proposed treatment is covered, and if there are any conditions for coverage. For example, some treatments may require prior authorization to confirm the medical necessity of the proposed treatment.
  3. Request a cost estimate from the hospital, ambulatory surgical center, or other facility where you will receive treatment. Usually your doctor’s charges for services are separate from the facility charges so you need to know the cost of both service providers.

You, your doctor, or your authorized representative can request an organization determination for the proposed service or treatment. Your Medicare plan will respond informing you about coverage for the service, the amount you can expect to pay, and any quantity limitations to the service or items.

  1. Know your provider’s relationship with Medicare

If you have Medicare Part A and Part B coverage, it’s important to know your provider’s relationship with Medicare because this determines how much you will pay for Medicare covered services.

  1. A Medicare participating provider accepts Medicare and takes assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. Your expense would be limited to the annual deductible, if applicable, and the coinsurance or copay amount.
  2. A non-participating provider accepts Medicare but does not agree to take assignment in all cases. You could be responsible for up to 35% of the Medicare approved amount for covered services in addition to any applicable deductible and copay or coinsurance.
  3. An “Opt-out” provider does not accept Medicare at all. This means the provider can charge whatever he or she wants for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You may be responsible for the entire cost of your care.

If you have questions about the cost of medical care or your Medicare coverage options, I would be happy to help you. You can contact me by using the links below. If you wish to compare some of the Medicare plans where you live, use the Compare Plans button on this page.

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Pamela Cannaday |
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