Ask The Medicare Specialist

QUESTION:

I’m a retired HR professional who Question from Gail: worked in the medical field and I know a lot about Medicare, but I always learn new things from you. In the last column you wrote, “Medical providers don’t even bill Supplement companies. They bill Medicare. Medicare has it on file who the beneficiary’s Supplement is with and coordinates getting the doctor or hospital paid in full.” Some related questions.

1) Why then, do medical providers always ask to see and copy our insurance cards for both Medicare and the Supplement if this is the case?

2) Once in a while the provider sends me a bill for the amount Medicare doesn’t pay, which obviously should have been covered by my Supplement. When I call billing and tell them this, the rep always says, “Oh, that information is missing from your file - I’ll add the name of your Supplement to it.” And then they tell me to ignore the bill.

3) When something like this happens, is the problem most likely a timing issue among Medicare, the Supplement, and provider’s billing process?

4) Should I be contacting Medicare or my Supplement company when this happens instead of the provider, or should I just not waste my time calling anyone and ignore these bills altogether?

ANSWER:

Let’s start from the top.

1) I’ve never asked this question of a provider so I can only make assumptions. The first of which is requesting all applicable insurance cards is what those at the reception desks are trained to do. However, knowing if someone has a Supplement or an Advantage Plan is important to a provider so they know if they can order tests, services, or procedures immediately or if they must call in an authorization. As I’ve written about 100 times in the columns; those on Supplements don’t need prior authorizations or approvals for CT scans, MRIs, biopsies, physical therapy, surgeries, infusion or injection therapy, etc. For example, if Gail went to an orthopedist with complaints of severe back pain, the doctor could tell her to return to the lobby and someone will get her to do the MRI asap. When the doc read the results and noticed a herniated disk, he or she could order surgery as soon as the next day. Getting care quickly without any interference or delay is the number one reason people are willing to pay more for a Supplement and forgo the extra benefits of Advantage Plans. Those on the latter are not able to have the procedures I listed done as promptly because an authorization from the Advantage Plan insurance company must be approved before those services can be performed. This generally takes about two weeks. Although not common, services can be denied, or delayed further if the insurance company decides they want the insured to get physical or injection therapy competed first.

2) I suspect anyone who gave Gail that nonsensical reply has decided it’s the easiest way to shrug off a billing error. Unfortunately, there are so many different insurances, so much confusion on coding, lots of turnover among those who work in billing and doctor’s offices that mistakes are common, understandable, and inevitable. That being said, unless Gail has the super expensive Supplement Plans C or F, there are some small out of pocket medical bills with Plans G and N. Both have a $240 deductible that resets every January 1st. N has two other co-pays after the deductible has been met, $20 at a physician’s office visit and $50 at the ER. I suggest to our clients that they keep a folder and put all their bills in it. The first to come in for 2024 should literally equal $240 to the penny. Those on G then know if any other bills come in, they’re almost certainly erroneous. Those on Plan N know that after they’ve met the $240, any bill they get other than their copays are also in error. The simplicity of Supplements is another reason people choose them.

3) I can’t even imagine how many millions of dollars a year seniors on both Supplements and Advantage plans pay for bills they should have never received. I estimate that 95% of the time people get one like Gail has, where she knows it’s wrong, there’s an error by the provider and it has nothing to do with the timing issues she mentioned. 4) Because of this, the provider should always be called first and immediately. Ignoring bills will likely lead to a collection notice as most errors don’t fix themselves. And don’t accept answers that the bill is correct when you’re convinced otherwise. I’ll give you an example. My grandmother has Supplement Plan N. She got a bill from her PCP of over $400 for her routine semi-annual visit. When I called to inquire on her behalf, someone in the billing department told me she had used up her lifetime Medicare allowances. That’s impossible with Medicare when it comes to doctor visits, or almost any service for that matter. I explained that to the representative who didn’t seem very interested in solving the issue before asking to speak to a supervisor. The person I was transferred to quickly found the problem. They had coded it as her annual wellness visit for a second time that year. Medicare approves only one annually, so the claim in question was denied. In response, the provider went ahead and billed my grandmother what they would have someone with no insurance despite the fact Medicare and a Supplement would have only reimbursed that code at about $100. Supplement companies have no idea if you went to the doctor unless Medicare covered their share. However, they can tell you if they’ve paid the provider or not for a service, so it can be helpful to call them when fighting with a billing department. Calling Medicare should be a last resort because you will likely spend 30 minutes or more on hold and possibly be disconnected during the call. Gail is not a client of ours. If she was, none of this would be an issue for her. When our clients get what they think may be a questionable bill, they simply contact us, provide a copy, and we handle the rest so they can avoid the hassles and runarounds that are almost certainly inevitable when it comes to insurance claims and medical billing departments.