How To Read Your Medicare Summary Notices
Question: I get Medicare Summary Notices (MSN), but I don’t understand them. The amount on the MSN does not match my doctor bill. How do I read this?
Answer: Whenever you go to see your doctor or are admitted to the hospital, your benefits are processed through your insurance provider. Depending on your insurance carrier, you either get a Summary Notice, or an Explanation of Benefits notice.
If you have traditional Medicare you receive in the mail a Medicare Summary Notice (MSN). This notice alerts you to the fact that a provider has billed Medicare, using your ID number for a service or office visit. You should review these notices to be sure that Medicare is being billed correctly. Check the notice for the physician’s name to be sure it is someone you saw. Check the date of service to be sure it is the correct date you saw them. Then check the name on top to be sure it is your MSN. I have once in a great while seen someone get someone else’s MSN by mistake.
These MSNs used to be mailed out on a monthly basis to all beneficiaries. Centers for Medicare & Medicaid Services (CMS) now mails them out quarterly. This means you probably get a larger envelope of notices less often.
If you take out one of these notices, the top says Medicare Summary Notice. Under that heading it will say “for Part A (Hospital Insurance)” or “for Part B (Medical Insurance)”
As you read down the page, it will tell you the date of service that this summary includes. Usually it is a three-month period of time May 14 to August 14. Next is a listing of your Deductible status. The Part A deductible is $1,384 for each hospital state. The Part B deductible is $185 per year. If you have met your deductible that will be indicated. If not it will show how much more you have to go until the deductible is met. The next section indicates whether the claims filed were approved or not.
The second page indicates how to answer questions, report fraud, illustrate rules or benefit periods. It also includes “Messages from Medicare”. These are notices or announcements that Medicare wants to communicate with everyone. These are usually printed on the last page or at the bottom of the pages. Medicare uses these announcements and notices as infomercials if you will.
The third page begins to illustrate your claims. The first section tells you information about your overall Medicare coverage and definitions of the different columns and what they mean.
The claims follow, but are not in chronological order. You will see a grey area listing the date of service and the service provider. This lists the doctor name and his participating group or clinic. It will include a Claim number (the number given to this individual claim) and the address of the individual billing Medicare.
The service date is the date when the visit, exam happened. Often there are two or three items listed. For example, it will list a date, April 29, one listing for an office visit, one listing for additional things that were done. This additional service could be educational training or other additional service.
The next column is Services Provided. This section usually includes what they billed for (an explanation of the services with a claim ID code). The next indicates if the claim was approved by Medicare.
The next column lists the Amount Charged to Medicare. This is usually a flat rate ($120 or $5,620.) Some physicians will bill the amount that Medicare usually approves ($96.88).
The next column is the Medicare Approved amount for that service/visit. Medicare has an approved amount for each type of service. The doctor codes your visit using the code numbers provided by Medicare to categorize coverage. Each code gives the doctor a particular reimbursement level. This is the Medicare Approved amount. This amount is usually significantly less than the doctor billed. For instance the doctor bills $120; Medicare approved $85.75 for that visit. That means the doctor will NOT be paid more than the total of $85.75 for that visit. I will describe this in detail in a minute.
The next column is the amount that Medicare Paid Provider. This column shows what Medicare actually paid on this claim. If you have not yet met your $185 deductible for 2019 the column will indicate zero. Once your $185 has been Medicare will pay 80% of the Medicare Approved amount.
The next column is what Maximum You May Be Billed. It uses the word “May” because you will pay this amount if you don’t have secondary insurance. If you have secondary insurance this amount will be sent onto that insurance provider. This amount would be 100% of the Medicare Approved amount unless you have met your $185 deductible. If you have met that deductible this amount should be 20% of the Medicare Approved amount.
Now I will put that in numbers; doctor bills $120, Medicare approves $85.75. If I have met my $185 deductible for 2019, Medicare pays $68.60 ($85.75 X 80%). Then I will have to pay $17.15 ($85.75 X 20%). But I have a Medicare Supplement policy which pays my Medicare Part B 20% co-pay amounts. So I actually pay zero.
After each claim there are usually letters (A, B, C. D, etc). The codes and their explanations are on the bottom of the page. Each notice you get has a different Notes Section. This Notes Section may indicate that your claim has been forwarded onto your secondary insurance carrier or other important information regarding these claims.
The last page of all claims is “How to Handle Denied Claims or File an Appeal.” This is a procedural page explaining what to do if you disagree with this decision. This section is exactly the same directions for each Medicare Summary Notice and can be reviewed if necessary.
There is also usually a sheet of paper describing how to get your MSN in a different language, or get them electronically “eMSN”. This piece of paper (two pages) are included in all claims and do not need to keep as you get them over and over.
If you have secondary insurance (Medicare Supplement, or Retiree benefits) you probably get a similar notice from that company as well. These should contain similar headings and explanations.
If you have questions or concerns about these claims you should call the contact information they provide, usually 1-800-MEDICARE (1-800-633-4227). You can also use your mymedicare.gov portal to handle these issues electronically.
If you have a Medicare Advantage Plan your notice would come from your provider, like Univera Senior Choice, or Today’s Options, or Independent Health Medicare Passport to name just three of the 29 plans available.
In this case, you would not receive a Medicare Summary Notice (MSN) because your claims are not processed through that that insurance system. The Explanation of Benefits (EOB) you receive would come on your insurance carrier’s letterhead with their explanation of coverage. The information provided will be very similar, but may have a different layout. If you have a Medicare Advantage Plan, and you have questions you would call your insurance company directly.
If after reviewing your MSN and your secondary EOB, you find the doctor’s bill does not match, I would speak to the billing person at your doctor’s office. There may be a ‘crossing in the mail’ issue or another reason for the different amount. You can usually resolve the issue by talking with the billing person at the office. If you still can’t come to an agreement you can always reach out to Medicare at (800) 633-4227.
To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at firstname.lastname@example.org.