Question: I got a hospital bill from my admission and the Rehab stay after. I didn’t think it would cost that much? How do I know what to pay?

Answer: I will answer this question over the next two weeks. As the answer is different depending on your insurance.

The key to maximizing your medical insurance coverage is first being sure providers (Doctor, Hospital, Pharmacy, & Lab, etc) have your CORRECT insurance on file.

Each medical visit or hospital stay should be billed to your insurance provider. The insurance carrier will either mail a Summary Notice or an Explanation of Benefits notice after they have process the claim.

I will begin with Original Medicare.

Original 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 (three month) schedule for both Part A (Hospital Insurance) and Part B (Medical Insurance). The MSN includes your Deductible status. (Part A deductible is $1632, Part B deductible is $240). If you have met your deductible that will be indicated on the MSN.

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 multiple items listed.

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 (ex; $175 or $18220)

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 $240 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 $200, Medicare approves $132.40. If the deductible is met, Medicare pays $105.92 ($132.40 X 80%). Then you will have to pay $26.48 ($132.40 X 20%). If you have a Medicare Supplement policy which pays the Medicare Part B 20%, you pay less.

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 how to get them electronically “eMSN”. This piece of paper (two pages) is included in all claims and does not need to be kept.

If you have secondary insurance (Medicare Supplement, or Retiree benefits) you get a similar notice from that company. If you have a Medicare Advantage Plan you get a notice from them instead of Original Medicare. I will be handling these topics next week, as there is too much to cover in just one article.

If you have questions or concerns about these claims you should call the contact information they provide, or 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 or EOB, 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.

Never pay a bill without an MSN, or EOB’s to match it to. Sometimes providers send bills before your insurance has had a chance to pay the bill on your behalf.

Be sure to check out next week’s article for more information.

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.