Medicare insurance causes new dilemma

By Judy Benge
50-Plus

September 15, 2008 09:15 pm

— Dear Judy: I will be on Medicare insurance soon and have a question. How does Medicare pay for the medical bills? Does the patient have to pay the doctor first and then get reimbursed from Medicare? Doctor bills and lab and other tests can be very expensive when you are on a fixed income. Can you enlighten those of us who will soon face this new dilemma?
Answer: When a patient is on Medicare Part B, which is the medical coverage, payments for your bills are made either directly to the doctor or supplier or to the patient.
If you go to a doctor who accepts assignment, which means the doctor agrees that he/she will accept the amount that Medicare approves for the service as the full payment, payment will go directly to the doctor. This is called the assignment method. Medicare advises that this is the best way to save the patient time and money.
The medical provider (doctor or supplier) sends the claim for your care directly to Medicare. This is the insurance company that pays claims in your area of service. Then Medicare pays the doctor or provider of service 80 percent of the amount determined to be the “approved charge.” You must have met your deductible for the year, for 2008 it is $135.
The doctor can only charge you for the 20 percent that is not paid by your Medicare insurance carrier under the assignment method if you have met your $135 deductible. He/she cannot charge you for the difference between your doctor’s actual charge and the amount Medicare has approved for the service. This can save you a lot of money throughout the year for medical services.
Remember that doctors and other providers of medical services in most circumstances are required to submit claims to your Medicare carrier for you, even if they do not accept assignment. Also, your doctor is required to send the claim within one year of service.
If you are enrolling in a prepaid health care organization, i.e. an HMO, claims are seldom submitted. A set amount is paid by Medicare to the HMO and the HMO provides medical care for its members. The doctors and other providers bill the HMO directly for reimbursement at contractually agreed prices.
Also, I advise everyone who is enrolled in Medicare to sign up for Medigap insurance to cover the bills that Medicare does not pay.
Some of these bills are the deductibles and coinsurance payments that can mount to more than most seniors can afford if you become chronically ill. And, as people age even the healthiest person can develop a serious illness.
Send your questions to judybenge@bellsouth.net.