Medicare novice here. Questions.

[omni550]

I've been on original Medicare for a few years now, with a Plan G Medigap policy, and Part D drug coverage.

I consider myself a novice and I'm still trying to learn the ropes. Luckily, I have been healthy, and haven't gotten past the Plan G deductible yet.

On Aug 15, 2017 I had some minor scalp excision thing done that my doctor took care of in-office. While I was there, the doctor suggested that I get Part 2 of a pneumonia shot, so I agreed. (Part 1 was administered during my first Medicare Wellness Visit in 2016.)

In August 2018, almost a year to the day, I received a bill from the hospital healthcare group to whom my doctor belongs, billing me for $126.11 (captioned "applied to deductible") which I paid after getting over the shock of being billed a year after the office visit. Then last week, I received another bill from the same outfit for the same office visit, this time for $39.00, for administration of the vaccine.

Questions: (Apologies in advance if these sound simplistic, but I've really never had many dealings with medical insurance "stuff".)

1. Is it typical for the billing of an office visit to be so untimely/late?
2. Is it typical to receive for multiple bills for the same visit from the same provider?
3. Do you keep all your paperwork and attempt to reconcile with what is shown on mymedicare.gov?
4. When/how is Medigap provider notified and get involved?
5. Am I supposed to be the checker/coordinator between Doctor/Medicare/Medigap etc.?
6. How do I know when I am finally done with a given claim?
7. When a doctor suggests something like a vaccine or a procedure, do I need call Medicare to find out if they cover it...or do I just go ahead with it and let the chips fall where they may (= most likely $$$ out of my pocket)?
8. Since I don't know what I don't know...is there anything else I should be asking/doing, either when face-to-face with my doctor or when presented with the claim charges?
9. Any suggestions/tips/tricks?

Thanks,

omni

 

[NoMoreJob]

Answers below in red......

I've been on original Medicare for a few years now, with a Plan G Medigap policy, and Part D drug coverage.

I consider myself a novice and I'm still trying to learn the ropes. Luckily, I have been healthy, and haven't gotten past the Plan G deductible yet.

On Aug 15, 2017 I had some minor scalp excision thing done that my doctor took care of in-office. While I was there, the doctor suggested that I get Part 2 of a pneumonia shot, so I agreed. (Part 1 was administered during my first Medicare Wellness Visit in 2016.)

In August 2018, almost a year to the day, I received a bill from the hospital healthcare group to whom my doctor belongs, billing me for $126.11 (captioned "applied to deductible") which I paid after getting over the shock of being billed a year after the office visit. Then last week, I received another bill from the same outfit for the same office visit, this time for $39.00, for administration of the vaccine.

Questions: (Apologies in advance if these sound simplistic, but I've really never had many dealings with medical insurance "stuff".)

1. Is it typical for the billing of an office visit to be so untimely/late?

That's a longer than normal delay but it sounds like it's legitimate from your description.

2. Is it typical to receive for multiple bills for the same visit from the same provider?

Sure, if there are multiple procedures or multiple issues being addressed in the appointment. I know that it's not uncommon to have a separate 'administration fee' for vaccines but sometimes some types of providers will charge them and other won't.

3. Do you keep all your paperwork and attempt to reconcile with what is shown on mymedicare.gov?

Absolutely. You should be able to reconcile with your MSN.

4. When/how is Medigap provider notified and get involved?

Medicare passes all the information along electronically to my Medigap carrier. I'm assuming it works this way with most if not all carriers.

5. Am I supposed to be the checker/coordinator between Doctor/Medicare/Medigap etc.?

You should reconcile the billings before you pay anything that is due from you. If things don't reconcile then ask questions to find out why. Insurers as well as provider billing departments and Medicare an help. Don't expect the doctor to know, although they may sometimes.

6. How do I know when I am finally done with a given claim?

When the balance is zero either because all billed amounts have been paid or adjusted.

7. When a doctor suggests something like a vaccine or a procedure, do I need call Medicare to find out if they cover it...or do I just go ahead with it and let the chips fall where they may (= most likely $$$ out of my pocket)?

It's safest to check with Medicare first although the provider can often tell you how the procedure is typically covered. For instance a flu vaccine is typically paid by Medicare Part B but a Shingles vaccine is covered under Part D (drug). Providers usually know these things but you can and probably should also look at MyMedicare.gov (or call) to verify what you're being told.

8. Since I don't know what I don't know...is there anything else I should be asking/doing, either when face-to-face with my doctor or when presented with the claim charges?

Just ask questions and double check with multiple sources to verify if you're not sure. You'll need to ask fewer questions as you learn more about the system.

9. Any suggestions/tips/tricks?

Don't assume anything.

Thanks,

omni

 

[Bamaman]

NoMoreJob seems to have answered your questions.

We find that Medicare works in mysterious ways.

Doctors and health facilities bill amounts are simply out of sight. Medicare pays a pittance of what they were billed--depending on the service and the applicable charges for the city in which services were performed in. They issue us and the doctor a notice telling us how much to pay. The doctor's office charges off the balance and sends us a bill for what Medicare says we owe them. And we pay'em when the statement is received that corresponds with prior notices.

What gets me is that Medicare payments are substantially different from city to city. Our medium size town has relatively low Medicare paybacks, and doctors are paid seriously less than in the major cities in our state. It doesn't seem fair.

 

[upset264]

I have a Medicare Advantage plan with Aetna. $0 monthly premium, including prescription coverage. I find anything else excessively complicated. I am limited to in network doctors, but that has not been a problem. The main thing that I look at is the $6700 max annual out-of-pocket. Worst case, I can live with that.

I recently received the annual notice of changes for 2019. 214 pages not including indexes and instructions. It amazes me that we can have a plan for the elderly that is a quagmire of part A, part B, Part D, supplement plans, advantage plans, and who knows what else.

 

[WhoDaresWins]

I will be eligible for Medicare in July 2019. I am trying to learn all I can about this confusing system. Like the OP, I also plan to purchase a Plan G Medigap policy and Part D prescription drug plan. I didn't think you had any extra charges with a Plan G. In PA providers cannot assess excess charges either.

 

[NoMoreJob]

I will be eligible for Medicare in July 2019. I am trying to learn all I can about this confusing system. Like the OP, I also plan to purchase a Plan G Medigap policy and Part D prescription drug plan. I didn't think you had any extra charges with a Plan G. In PA providers cannot assess excess charges either.

I'm not sure what you mean by 'extra' charges. If you mean paying the Medicare Part B deductible (currently $183/yr) then yes, you must pay this yourself. That's the difference between Plan F (deductible paid my Medigap plan) and Plan G (deductible paid by you).

If PA does not allow excess charges then it should be a non-issue for you. Both G and F pay excess charges where they are assessed. Excess charges currently are not all that common but are possible with certain providers.

 

[omni550]

NoMoreJob -- Thank you for your detailed and very helpful response in post #2!

I will be eligible for Medicare in July 2019. I am trying to learn all I can about this confusing system. Like the OP, I also plan to purchase a Plan G Medigap policy and Part D prescription drug plan. I didn't think you had any extra charges with a Plan G. In PA providers cannot assess excess charges either.

WhoDaresWins -- As stated in post #1, I had not met my 2017 deductible under Plan G, so I was responsible for the first $183. (For the record, I did save MORE than $183 in the difference in premiums I paid between Plan F and Plan G.)

omni

 

[omni550]

How do you keep track of things?

Next novice question: So for complex medical circumstances (beyond a quick doctor's office visit/procedure), how do you folks handle this paperwork nightmare? Digital or paper? Notes, spreadsheets, stapled-together documents, or what?

I figure if I can get a reasonable system in place now, I'll be better prepared for whatever the future may hold.

ommni

 

[Gotadimple]

What gets me is that Medicare payments are substantially different from city to city. Our medium size town has relatively low Medicare paybacks, and doctors are paid seriously less than in the major cities in our state. It doesn't seem fair.

Because the cost of living is not the same in Chicago as it is in Lexington. They still need to pay the rent on their facilities and equipment, and those costs differ, as do salaries for staff. While Medicare coverage is the same across the country, the fee schedule differs by locality.



- Rita

 

[NoMoreJob]

Next novice question: So for complex medical circumstances (beyond a quick doctor's office visit/procedure), how do you folks handle this paperwork nightmare? Digital or paper? Notes, spreadsheets, stapled-together documents, or what?
ommni

Paper MSNs and provider billings - matched up.
Spreadsheets are typically not necessary IMO - I had one situation where a spreadsheet was helpful but it was an exception, not the rule.
Notes of all conversations to straighten out questions kept with or on the billing/MSN.

I can't imagine trying to do this all digitally although I'm sure that some are more proficient at it than I would be.

When working with a provider to straighten out a question work as fast as they will go to get the problem worked out and make sure it is clear that your goal is to pay the proper amount, not stall.

 

[DeborahB]

I have Plan F at the moment. I really don’t pay for anything beyond the premiums. When I go to the doctor there’s no co-pay. Unfortunately I have to see doctors frequently. So I wonder what they are billing you for, unless this is to satisfy the deductible. Most providers accept what they get and don’t bill for the difference. I don’t know for certain, but I think they are supposed to accept what Medicare will pay and discount the bill. That’s been my experience.

I haven’t looked at plan G vs F but I am told they work the same. If not, I’m hanging onto F!

 

[omni550]

Paper MSNs and provider billings - matched up.
Spreadsheets are typically not necessary IMO - I had one situation where a spreadsheet was helpful but it was an exception, not the rule.
Notes of all conversations to straighten out questions kept with or on the billing/MSN.

I can't imagine trying to do this all digitally although I'm sure that some are more proficient at it than I would be.

When working with a provider to straighten out a question work as fast as they will go to get the problem worked out and make sure it is clear that your goal is to pay the proper amount, not stall.

Thanks.

As these 2 recent bills were for services rendered in Aug. 2017, I assume any payments I make now will be credited towards my 2017 deductible, correct?

IOW, payments are credited towards deductible in the year the service was rendered, not towards the deductible in the year when paid.

If this^ is the case, will my Medigap Provider keep tabs on this and pick up the tab once my 2017 deductible has been met (even if it is in 2018)? Or do I need to "remind" them?

omni

 

[omni550]

Another novice Q.

As I have started digging through my medical paperwork (for as few instances as I have needed care) from the past several years, I now see that there were several occasions where I promptly paid a bill from the provider, only to later find out that THEY owed me money (due to double-billing once, etc.). It took endless phone calls, over 3-4 months, for me to finally get them to refund what was owed to me. It sure felt like they were not going to ever refund me, had I not badgered them every few weeks.

I recall reading on another forum thread last week to always wait until you'e been billed twice before paying. Is this a good protocol to follow?

omni

 

[REWahoo]

I recall reading on another forum thread last week to always wait until you'e been billed twice before paying. Is this a good protocol to follow?

omni

Better yet, wait until Medicare sends you the EOB (Explanation of Benefits), which might take a couple of months. That will spell out what you should pay - and what you should not.

 

[NoMoreJob]

Thanks.

As these 2 recent bills were for services rendered in Aug. 2017, I assume any payments I make now will be credited towards my 2017 deductible, correct?

IOW, payments are credited towards deductible in the year the service was rendered, not towards the deductible in the year when paid.

If this^ is the case, will my Medigap Provider keep tabs on this and pick up the tab once my 2017 deductible has been met (even if it is in 2018)? Or do I need to "remind" them?

omni

You are correct. Date of service is the key for Medicare and Medigap and they will be consistent.

 

[NoMoreJob]

Better yet, wait until Medicare sends you the EOB (Explanation of Benefits), which might take a couple of months. That will spell out what you should pay - and what you should not.

+1

Check all billings against the MSN (Medicare equivalent to EOB) before paying.

FYI, you can see them on your MyMedicare account prior to receiving the mailed copy - these are called eMSNs. I also receive email notifications when a new eMSN is available on my account. That said, I wait to receive the mailed copies just so I'm not shuffling extra paper, but if one is lost in the mail it is always available through your online account. The system is very good once you get the hang of it.

 

[aja8888]

My DW has 6 different doctors and 13 prescriptions. She has had a heart valve replaced, has COPD, severe osteoporosis, and a few more things. She has full plan F. We have never had to pay anything for a doctor or facility service since she was on Medicare (7 years ago).

Prescriptions? Cost us about $5K OOP (Part D).

Omni, the best advice I could give you is to call Medicare anytime someone recommends anything, especially vaccines. On G, you will have an annual deductible.

If you haven't sign up for the Medicare site and there is a ton of info and your account details. Plus, you can see what you are eligible for with regards to the annual Wellness visits.

Also, with Plan G, never pay any of the deductible at the doctor's office even of they ask for it. Medicare will determine who gets the deductible and you will be billed for it after that. It should be shown on the EOB from Medicare.

 

[omni550]

Slowly, this is becoming a bit clearer.

Next Q. --

How do I know/see what my Medigap insurer is paying/has paid towards a procedure/office visit? Does that show up on the eMSN/MSN? Does Medigap provider send out statements?

omni

 

[REWahoo]

Next Q. --

How do I know/see what my Medigap insurer is paying/has paid towards a procedure/office visit? Does that show up on the eMSN/MSN?

No.

Does Medigap provider send out statements?

Yes, their own EOB. May be either paper or electronic, depending on what systems they have and what choice you make in how you want to receive them.

 

[DeborahB]

My DW has 6 different doctors and 13 prescriptions. She has had a heart valve replaced, has COPD, severe osteoporosis, and a few more things. She has full plan F. We have never had to pay anything for a doctor or facility service since she was on Medicare (7 years ago).

Prescriptions? Cost us about $5K OOP (Part D).

Omni, the best advice I could give you is to call Medicare anytime someone recommends anything, especially vaccines. On G, you will have an annual deductible.

If you haven't sign up for the Medicare site and there is a ton of info and your account details. Plus, you can see what you are eligible for with regards to the annual Wellness visits.

Also, with Plan G, never pay any of the deductible at the doctor's office even of they ask for it. Medicare will determine who gets the deductible and you will be billed for it after that. It should be shown on the EOB from Medicare.

My advice - don’t pay anything to a doctor’s office until you have the Medicare paperwork and the plan g provider’s paperwork.

 

[omni550]

Thanks, everyone, for the helpful information.

This thread got me going through all the Medicare paperwork I've just randomly stuck in a folder, as I couldn't quite figure the entire process out before.

Turns out, the $39 bill I received just last week for an injection of pneumococcal vaccine administered during an Aug. 2107 office visit was declined by Medicare. Calls to Dr. office and my Medigap provider confirmed this.

The vaccine was approved but not the injection? This makes zero sense, especially since they had covered the same vaccine and injection the prior year.

So today I am mailing in my 1st level of appeal to Medicare (via their Redetermination Request Form) and will wait to see how this gets resolved.

And they ask what retirees do all day. Sheesh.

omni

 

[REWahoo]

Sounds like you are quickly moving from Medicare "novice" to "expert". Soon you will be answering our Medicare questions!