Question; My doctor just sent a bill from my last visit, but I don’t think I pay doctor bills. 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 provider. The insurance carrier, will either mail a Summary Notice or an Explanation of Benefits notice.

Traditional Medicare recipients receive 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. Review these notices to be sure the physician’s name, the date of service are accurate.

MSNs are mailed out by Centers for Medicare & Medicaid Services (CMS) on a quarterly (09-01 to 11-30-22) schedule for both Part A (Hospital Insurance) and Part B (Medical Insurance). The MSN includes your Deductible status. (Part A deductible is $1556, Part B deductible is $233). If you have met your deductible that will be indicated.

The next section illustrates your claims. The claims are not in chronological order. Claim information includes the doctor 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. Often there are two or three items listed. For example, it will list a date, 9/13/22, 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 $5620.)

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 $233 deductible (in 2023- $226) 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. Until your deductible is met, this amount would be 100% of the Medicare Approved amount. If you have met that deductible this amount should be 20% of the Medicare Approved amount.

Now an example, the doctor bills $120, Medicare approves $85.75. If I have met my $233 deductible for 2022, 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, 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”. This piece of paper (two pages) are included in all claims and do not need to keep.

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 www.medicare.gov portal to review these claims electronically.

If you have a Medicare Advantage Plan your notice would come from your provider. In this case, you would NOT receive a Medicare Summary Notice (MSN) because your claims are NOT processed through the Medicare 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. When you have a Medicare Advantage Plan, and you have questions you would call your insurance company directly.

If you find the doctor’s bill does not match your MSN or EOB, 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 physician’s office. If you still can’t come to an agreement you can always reach out to Medicare at 1-800-MEDICARE.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email at SLM@lutheran-jamestown.org.