How do they reconcile Medicare Part B deductible?

[fh2000]

This is the first year that I actually used Medicare/Plan G service.

I had a Wellness check by my primary doctor with blood test in his office, but I do not see my Medicare.gov account for his claim.

I then had colonoscopy with my gastroenterologist. I see the claims for his initial consultation, surgical center, his colonoscopy procedure, pathologist, and the LAB.

The amounts in Medicare claim report, under 'You may be billed' are totaling more than the deductible amount, $233.

I wonder how each party know what my remaining deductible is, and how they each reconcile their portion of the charge. Do they all first bill Medicare, then bill the Plan G provider, then send me a bill for remaining deductible? If I get a bill but I had already paid all my deductible, do I then tell them to go back and reconcile with Medicare and/or Plan G provider?

 

[athena53]

According to a friend who answers questions from Medicare beneficiaries through a call center, it's not all that well-co-ordinated. Let's say that you have no outstanding claims and $250 of your deductible remaining. You go to Doc A on Monday and Doc A tells you to pay $250 up front for treatment that will cost more than $250. You see Doc B on Tuesday and Doc B wants $250 as well, also for treatment costing $250+.

Eventually the second to get reimbursed will get full reimbursement because the deductible will have been absorbed in the first claim. It's then up to the doc to reimburse you the excess $250 you paid.

 

[audreyh1]

DH has never been asked for Medicare deductible up front by a provider. Or even whether he has met the deductible that year.

 

[Telly]

Yup! If you have deductible left, it can be a toss-up of who gets first when different providers are scheduled close together.

The process is, provider submits to Medicare. Medicare responds by paying ~80% of the amount they authorize (if authorized), taking into account any unpaid deductible. Then Medicare sends the remaining 20% (assuming all deductible has been paid) on to the Medigap provider. So don't pay anything too quickly. I try to avoid the "which provider runs out the deductible first" issue by trying to keep some time between visits, so I don't have to try to squeeze $ back out of a provider. Easiest way to avoid this problem is to have the first provider you go to for the year, use ALL of your deductible! Okay, maybe that's not the best wish for the status of your health!

 

[Telly]

DH has never been asked for Medicare deductible up front by a provider. Or even whether he has met the deductible that year.

I did when I went to a PCP I hadn't gone to before, and had all the deductible to go. They wanted $ at checkout. This was the start of a not-so-good experience. This was reinforced by other not-so-good experiences with their staff and PA in two other later visits. I'm looking for a new PCP now.

EDIT: The providers who have many Medicare patients, and are not crooks (the providers, not the patients!) seem to have their Medicare billing act together, and know how to handle it. For those with few Medicare patients, (or those looking to pick up as many $ out of you as they can like my now ex-PCP), it can be a bit clumsy.

 

[PatrickA5]

Not on Medicare yet, but same problem comes up with regular insurance. When I have tests/Dr visits, they tend to try to get me to pay upfront. I always refuse because I've found it hard in the past to get reimbursed once you overpay.

There have been a few places that just refused to perform the service without upfront payment, but nothing in the last several years.

 

[Sarah S]

I found the medicare process for close together visits worked very well. They applied the remaining deductible to what I think was the first bill they received and then it was all paid by medicare and my supplement. I do find that it takes a while to get the deductible bills from the providers. No one has asked for advance payment of deductible for medicare. It happened occasionally with my previous insurance. The one time I had close together visits the second one asked for it and I explained that there would be another party also billing. They were good with waiting to see

 

[fh2000]

So, after you paid portion of the deductible amount, will that provider then report back to Medicare.gov that how much deductible you actually paid?

 

[audreyh1]

So, after you paid portion of the deductible amount, will that provider then report back to Medicare.gov that how much deductible you actually paid?

I don’t think Medicare looks into what you have paid any given provider. They plus the Medigap company just dictate what you can be billed by any given provider.

 

[CRLLS]

I'm on Medicare for 5 years now. This year I had to have a pre-op checkup. I went to a Physicians Express. Never been there before. On check-in. after taking all of my insurance information, they said asked for payment up front. I said I'm on Medicare. They said "It is our policy to collect payment for services up front. If Medicare pays us, we refund your payment." I stopped for a minute of thought, then said" My policy is to wait for Medicare, the Supplement and the Dr's bill to all agree and then if there is a balance due, I pay the balance. How do we reconcile this?" They agreed to just wait.

That is the only time I have been asked to pay up front.

 

[audreyh1]

Not on Medicare yet, but same problem comes up with regular insurance. When I have tests/Dr visits, they tend to try to get me to pay upfront. I always refuse because I've found it hard in the past to get reimbursed once you overpay.

There have been a few places that just refused to perform the service without upfront payment, but nothing in the last several years.

The situation is vastly improved with Medicare.

 

[audreyh1]

I'm on Medicare for 5 years now. This year I had to have a pre-op checkup. I went to a Physicians Express. Never been there before. On check-in. after taking all of my insurance information, they said asked for payment up front. I said I'm on Medicare. They said "It is our policy to collect payment for services up front. If Medicare pays us, we refund your payment." I stopped for a minute of thought, then said" My policy is to wait for Medicare, the Supplement and the Dr's bill to all agree and then if there is a balance due, I pay the balance. How do we reconcile this?" They agreed to just wait.

That is the only time I have been asked to pay up front.

Good personal policy statement! I think I’ll steal it.

 

[Rianne]

I have MoO plan G. In the MoO site, each EOB specifically spells out the details of the service, what medicare paid, what MoO paid and the part B deductible paid or remaining. Each EOB is in chronological order.

I like how the site is set up, very easy to understand. I'm kind of shocked at how little medicare pays for services. Wow, they really negotiate down the cost of healthcare.

 

[Venturer]

I'm on Medicare for 5 years now. This year I had to have a pre-op checkup. I went to a Physicians Express. Never been there before. On check-in. after taking all of my insurance information, they said asked for payment up front. I said I'm on Medicare. They said "It is our policy to collect payment for services up front. If Medicare pays us, we refund your payment." I stopped for a minute of thought, then said" My policy is to wait for Medicare, the Supplement and the Dr's bill to all agree and then if there is a balance due, I pay the balance. How do we reconcile this?" They agreed to just wait.

That is the only time I have been asked to pay up front.

I have MoO plan G. In the MoO site, each EOB specifically spells out the details of the service, what medicare paid, what MoO paid and the part B deductible paid or remaining. Each EOB is in chronological order.

I like how the site is set up, very easy to understand. I'm kind of shocked at how little medicare pays for services. Wow, they really negotiate down the cost of healthcare.

I had the same thing happen recently when I had to go to a Urgent care on a Saturday. They ask for payment, I said when I called the lady said you accepted Medicare, I have already met my deductible for the year so I don't have to pay. She then said we will bill you later if your insurance doesn't pay. I never heard back from them but I did get the Statement where they were paid. I never pay anyone upfront anymore. Wait and see who Medicare says I may owe,and then wait for the bill to come. It really is a lot simpler than the merry go round when I was working. Medicare and plan G MoO is great!

 

[Trooper]

I'm on Medicare for 5 years now. This year I had to have a pre-op checkup. I went to a Physicians Express. Never been there before. On check-in. after taking all of my insurance information, they said asked for payment up front. I said I'm on Medicare. They said "It is our policy to collect payment for services up front. If Medicare pays us, we refund your payment." I stopped for a minute of thought, then said" My policy is to wait for Medicare, the Supplement and the Dr's bill to all agree and then if there is a balance due, I pay the balance. How do we reconcile this?" They agreed to just wait.

That is the only time I have been asked to pay up front.

Good personal policy statement! I think I’ll steal it.

That's brilliant! I'm stealing too.

 

[Midpack]

DH has never been asked for Medicare deductible up front by a provider. Or even whether he has met the deductible that year.

Just the opposite here, works perfectly for us every year. I’ve been Medicare for 3 years and I’m asked to pay on my first visit every year as I haven’t met my deductible. On every subsequent doctors visit each year doctors seem to know I’ve met my deductible and charge accordingly. I guess the only explanation is my first visit every year is a physical with my GP, and her office staff is savvy enough to handle Medicare deductibles correctly. So maybe it depends on providers as much (or more) than Medicare?

 

[teej1985]

Just the opposite here, works perfectly for us every year. I’ve been Medicare for 3 years and I’m asked to pay on my first visit every year as I haven’t met my deductible. On every subsequent doctors visit each year doctors seem to know I’ve met my deductible and charge accordingly. I guess the only explanation is my first visit every year is a physical with my GP, and her office staff is savvy enough to handle Medicare deductibles correctly. So maybe it depends on providers as much (or more) than Medicare?

Medicare doesn't cover physicals, so that would be one reason.

 

[MRG]

That's brilliant! I'm stealing too.

++

This was my first year on Medicare starting February, and I had surgery in March. The pre-op guy asked if I'd like to pay up front, and I said sure. Never again. It did get worked out, and the surgery place sent me a check after the end of the quarter. I mentioned the hassle, and they sounded surprised and said it wasn't a requirement to prepay.

 

[Midpack]

Medicare doesn't cover physicals, so that would be one reason.

The OP asked about Medicare with a Plan G, so that’s what I replied to.

Actually Medicare covers a basic wellness check, and some practices code such that Medicare and our supplemental does pay for some (not all) additional testing - 3 straight years in my case. I’m getting a decent physical every year regardless, but somehow our GP manages to have Medicare and our supplemental pay for a good chunk of our physicals - I never assumed or asked her too either.

 

[RetMD21]

Medicare doesn't cover physicals, so that would be one reason.

The don't pay for physicals billed as preventive but if you have virtually any medical condition they can use that code to get paid if they want