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Question: My doctor just sent a bill from my last visit and a procedure they completed, but I don't think I should pay this much. How do I know what to pay?
Answer: Whenever you go to see your doctor, have a procedure, or are admitted to the hospital, your benefits are processed through your insurance carrier. The insurance carrier will either mail a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB) notice to explain how they covered that claim.
This week, we will review how Original Medicare handles those claims and notifies you of the coverage. Next week we will cover Medicare Advantage Plans, which can be a little different. For now, just remember that if you have a
Medicare Advantage Plan, your EOB would come from your provider, and you would NOT receive an MSN.
MSNs are mailed out by Centers for Medicare & Medicaid Services (CMS) every six months for both Part A (Hospital Insurance) and Part B (Medical Insurance).
This is a new timeline, because CMS used to mail them out quarterly. Waiting six months for an MSN may be a problem as providers don't like waiting that long to get their payment, from you. You can sign up for electronic MSN's by calling 1-800-MEDICARE, or using your www.medicare.gov login. If you sign up for that electronic method, you will receive them via email monthly. If you don't use email or a computer, you can also use those contact tools to request a particular MSN be mailed to you sooner.
There is a lot of information in each MSN, and you can use it all to ensure you've been billed accurately. The MSN includes your Deductible status (Part A deductible is $1736, Part B deductible is $283). If you have met your deductible, that will be indicated.
The next section of the MSN illustrates your claims. The claims are not in chronological order. Claim information includes the doctor's name, participating
group or clinic, a claim number (the number given to this individual claim), the address of the individual billing Medicare, and the service date of the claim. There are often two or three items listed. For example, it will list a date, 7/21/26, one listing for an office visit, one listing for additional things that were done.
The next column is Services Provided. This section usually includes what they billed for (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 ($120 or $5,620)
The next column is the Medicare Approved amount for that service/ visit. Medicare has an approved amount for each type of service. The doctor uses the codes to categorize coverage. Each code gives the doctor a particular reimbursement level (the Medicare Approved amount).
The Medicare Paid Provider column shows what Medicare actually paid on the claim. If you have not yet met your $283 deductible, then the column will indicate zero. Once your deductible has been met, 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 billed to that insurance provider. Your secondary insurance will also send you an EOB which can be used to determine your cost share.
Until your deductible is met, the amount you 'may' owe would be 100% of the Medicare Approved amount. If you have met that deductible, then this amount should be 20% of the Medicare Approved amount.
So for example, the doctor bills $120. Medicare approves $85.75. If you have met the $283 deductible for 2026, Medicare pays $68.60 ($85.75 X 80%). Then you will have to pay $17.15 ($85.75 X 20%). But you may have a Medicare Supplement policy which pays my Medicare Part B 20% co-pay amounts. So you actually pay zero.
After each claim there are usually letters (A, B, C, etc), with their explanations on the bottom of the page.
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.
There is also usually a sheet of paper describing how to get your MSN in a different language, or get them electronically "eMSN". You do not need to keep these pages.
If you have secondary insurance (Medicare Supplement or employer group coverage) 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 www.medicare.gov portal to review these claims electronically.
If you find the doctor's bill does NOT match your MSN, I would speak to the billing department 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 department. If you still can't come to an agreement, you can always reach out to Medicare at 1-800-MEDICARE.
I strongly recommend that you never pay ANY medical bill you receive without first checking with your MSN from Medicare or EOB from your insurance company. Providers will often bill you at the same time they are filing a claim with your insurance company. So wait for your insurance company to determine what you owe.
Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.