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Question: My doctor just sent a bill from my last visit & 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 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. This week we will review how Medicare Advantage Plans handle those claims and notify you of the coverage status. Last week we covered how Original Medicare handles your claims.
Like Original Medicare, Medicare Advantage Plans receive claims from your physicians, providers, and hospitals whenever you access healthcare. It is also important to remember that if you have a Medicare Advantage Plan, your EOB would come from your provider, and you would NOT receive an MSN.
The Claims department of your Medicare Advantage Plan processes those claims to determine the amount the insurance company will pay compared to the amount the provider billed.
Most Medicare Advantage Plans have a copay for most procedures, which is a flat rate you would owe. This cost could be $5 for an office visit or $55 for an x-ray or $1800 for a hospital stay. Some Medicare Advantage Plans use a coinsurance rate, which is usually a percentage, 20% or 40% of the approved cost. The key words in the at sentence is "approved cost."
When your visit/ procedure has been processed, your Medicare Advantage Plan will mail you an Explanation of Benefits (EOB) for each claim. Very often their EOB's contain multiple claims in the same mailing. Medicare Advantage Plan tend to process claims and mail you the EOB as soon as they processed, unlike Medicare which mails them every six months.
Last week we talked about how a physician bills $120 for an office visit. With a Medicare Advantage Plan that still happens, but let's say your copay is $5 for that visit. The EOB you receive will reflect this $5 cost share. The remainder is not necessarily paid by your insurance because the Medicare Advantage Plan has negotiated a lower rate of pay for that. But that doesn't impact your cost share. The provider has agreed to that lower rate of payment when they signed the contract with the Medicare Advantage Plan.
If your plan is a PPO plan, you may be seeing Out Of Network (OON) providers, and this would normally be billed at a coinsurance rate, so a percentage. For example, let's say 30%.
In this situation you wouldn't pay that on the $120 claim. The insurance company sets the approved price, and then you pay that 30% of the approved price. So the approved amount for the visit is $92.75. Your 30% cost share for that OON provider is $27.82 (92.75 X 30%= $27.82). It would NOT be $120 X 30%=$36.00.
The insurance company rarely pays full price for any medical procedure. There is almost always some amount of write-off for all providers and procedures. Your Medicare Advantage Plan provided you with a Summary of Benefits or Evidence of Coverage book when you joined the plan. This document can provide you with your expected copays for these visits & procedures. You can check this to determine if the bill your provider sent you matches what the plan states your cost share should be. If you cannot find these documents, you can use your EOB's as a way to determine your cost share. The Medicare Advantage Plans usually mail the EOB's out monthly, so again you should never pay a bill without cross checking against your insurance carriers documents, either EOB or Summary of Benefits book.
Once you have cross-checked this information, you can go ahead and pay the bill if it matches what you should expect to pay. If it doesn't match, you could call your doctor to see what the discrepancy is. You can ask for the billing department and they should be able to speak with you.
Again I say never pay more than your insurance company states you should pay for your visits/ procedures. Providers will often bill you, the patient, at the same time they are filing a claim with your insurance company. So, wait for the insurance company to determine what you owe before you pay the bill. When you have a Medicare Advantage Plan, and you have questions, always call your insurance company directly - their Member Services number is located on the back of your card.
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.