How are Bills Paid in Original Medicare?

If you get a Medicare-covered service, like a lab test or doctor’s visit, you will get a Medicare Summary Notice (MSN) in the mail. The MSN shows all the services or supplies that were billed to Medicare during each 3-month period, what Medicare paid, and what you may owe the provider. The MSN isn’t a bill. When you get your MSN, you should do the following:

·         If you have other insurance, check to see if your other insurance covers anything that Medicare didn’t.

·         Keep your receipts and bills and compare them to your MSN to be sure you got all the services, supplies, or equipment listed.

·         If you pay a bill before you get your MSN, compare your MSN with the bill to make sure you paid the right amount for your services.

MSNs are mailed out every 3 months. If you are due a refund check from Medicare, the MSN will be mailed out as soon as the claim is processed. If you need to change your address on your MSN, call Social Security.  We have their contact information here, click here to go to the page.  

What if I have other health insurance?

Tell your doctor and hospital that you have other insurance so they will know how to handle your bills correctly. If you have Original Medicare and you have questions about how it works with your other insurance, or you need to update your other health insurance information, call the Coordination of Benefits Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782. 

What if I need a health care service or supply that Medicare doesn’t cover?

If you have Original Medicare and your health care supplier or provider thinks that Medicare probably (or certainly) won’t pay for certain services for you, the supplier or provider must tell you in writing. This is called an Advance Beneficiary Notice, or ABN, and it explains what items and services Medicare won’t pay for and why. You will be asked to choose an option on the ABN indicating whether you still want to get the service and to sign the ABN. If you choose to get the service listed on the ABN, you must agree to pay if Medicare doesn’t pay.

An ABN isn’t an official denial of coverage by Medicare. You can still ask your health care provider or supplier to submit the bill to Medicare. If payment is denied, you can file an appeal. If you aren’t sure if Medicare was billed for the services you got, call or write to the health care provider and ask for an itemized statement. This statement will list each Medicare item or service you got from your health care provider.  

What happens if Medicare doesn’t pay for a health care service or supply?

After you get a service or supply, your provider should bill Medicare. Later, Medicare will send you a Medicare Summary Notice (MSN) that describes the bills it got from your providers. The MSN will also tell you whether Medicare paid the bills. Read it carefully. If Medicare didn’t pay for a service or supply, and you think it should have, you have 120 days from the date you get the notice to file an appeal. The back of your MSN will have information on how to file an appeal.

If you are getting Medicare-covered services from a hospital (as an inpatient), skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your services are ending too soon, you may have the right to a “fast appeal.” This fast appeal is also called an “expedited determination.” An independent reviewer will decide if your services should continue. 

Protect Yourself and Medicare from Billing Fraud

Most doctors, pharmacists, plans, and other health care providers who work with Medicare are honest. Unfortunately, there may be some who are dishonest.

Medicare is working with other government agencies to protect you and the Medicare Program from such dishonesty. Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud takes a lot of money every year from the Medicare Program. You pay for it with higher premiums. A fraud scheme can be carried out by individuals, companies, or groups of individuals.

 The following are examples of possible Medicare fraud:

·         A health care provider bills Medicare for services you never got.

·         A supplier bills Medicare for equipment different than what they provided to you.

·         Someone uses another person’s Medicare card to get medical care, supplies, or equipment.

·         Someone bills Medicare for home medical equipment after it has been returned.

·         A company offers a Medicare drug plan that hasn’t been approved by Medicare.

·         A company uses false information to mislead you into joining a Medicare plan.

If you suspect billing fraud, here’s what you can do:

1. Contact your health care provider to be sure the bill is correct.

2. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

3. Call the Inspector General’s hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.   

Protect Yourself from Identity Theft

It’s also important to keep your personal information safe. You have control over when you provide and who you allow to have your personal information. 

Generally, no one should call you or come to your home uninvited selling Medicare-covered products. Don’t give your personal information to someone who does this. Only give personal information to doctors, other providers, and plans approved by Medicare, and to people in the community who work with Medicare, like your State Health Insurance Assistance Program (SHIP) or Social Security. Call 1-800-MEDICARE (1-800-633-4227) if you aren’t sure if a provider is approved by Medicare. TTY users should call 1-877-486-2048.

If you think someone is using your personal information, you can call any of these numbers:

·         1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

·         The Fraud Hotline of the HHS Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.

·         The Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338 to make a report. TTY users should call 1-866-653-4261. For more information about identity theft, visit www.consumer.gov/idtheft on the web 

The Senior Medicare Patrol Program Can Help You

The Senior Medicare Patrol (SMP) Program educates and empowers people with Medicare to take an active role in detecting and preventing health care fraud and abuse. There is a SMP Program in every state, the District of Columbia, Guam, U.S. Virgin Islands, and Puerto Rico. To find your state’s SMP Program, click here.