When my daughter was in 8th grade they wanted her to have an MMR booster. My insurance did not pay for Dr visits. My daughter thought she broke her ankle so DH took her to the doctor. He was charged $40 for the visit, which he paid. (This was 1998) I got a statement from BC saying that they covered the visit because it was an accident, $35. I figured I'd just leave that as a credit at the Drs and use it the next time there was a Dr. visit. I called to set up the booster, told the cost, and then I asked about the $35 credit. There was no credit on the books. Well I have proof. Need to talk to the billing clerk. Clerk told me she needed to research. When she started giving me the run around I wrote the doctor, no call from him. I then called BC. One of the problems with the billing clerk was she was only going to refund me $35. I said no, $40. BC paid her what she was owed under contract she owed me $40. BC agreed with me called the billing clerk and told her to refund the $40 DH had paid. I got the refund of $40 in a money order not the Drs check. Found out later the clerk was let go because she was stealing. She fooled with the wrong person because I worked at accounts receivable and collections. My background has helped me sort out mistakes billing departments have made.
Sometimes the problem is more easy to resolve with a few phone calls, like you did. And not putting it off for later is also a good idea.
Other times, as has been my experience, they just do not know the answers, (doctor's staff, insurance staff), and then they lie. Spending more than a few hours in one day on these issues can be extremely stressful, and they are not listening. I don't know every detail of their rules, but I know enough to understand when they are wrong. And if they are not wrong, they should explain why. Result: I have given up way too many times.
Like what Sendhelp said. New one, never knew a Doctor could bill Medicare as a courtesy.
You need to see the statement from Medicare showing you why they did not pay or ur MA. I am on straight Medicare. I had a Mammogram in 2021. I have a Medicare statement/summary telling me that part of the service preformed was not covered by Medicare. Also, I was not responsible for the charge if they tried to bill me.
So as I said, knowing if your straight Medicare or a Medicare Advantage is important.
Type I: Does the doctor 'Accept Medicare Assignment' ? Means they are enrolled as a Medicare provider, bill Medicare, and accept payment in full from Medicare. In full means whatever Medicare has allowed and approved. They cannot seek payment from the patient because they are under a Medicare contract with Medicare.
Type II: A doctor can bill Medicare for you as a courtesy, but expect you to pay a difference between what Medicare paid and the bill. This is called a 'limiting charge', up to about 15% in many states. In other words, this doctor does not accept Medicare assignment as payment in full. The doctor must inform you, and likely did in advance on the papers you signed to receive care at the office.
Type III: The doctor may have 'Opted Out' of Medicare altogether (No Medicare contract), and cannot bill Medicare, and Medicare will not reimburse you to be seen by this doctor.
Type IV: The doctor's billing staff is unaware they are billing for charges that are not due from the patient.
For you to get the correct answers here and be pointed in the right direction, we really need to know if your on a Medicare Advantage plan or Straight Medicare with a supplimental. Big difference in how the two operate.
You will receive notification from the insurance if they do not cover. Medicare will cover. Whether supplemental does or not will depend on whether MD is in that network (if an advantage policy) or whether the consult was approved or not. Did they submit to medicare? Who is managing the medicare for this person, and getting the billing? It is up to them to investigate this. Simply tell the neuro office, if medicare didn't cover it is a problem with their coding, and to rebill. Call the supplemental if you have a refusal in hand. In other words, you must check with your own insurance. But yes, medicare covers all doctor in one way or another, and this sounds like a problem that falls under "other". You will be busy on the phone for a while I am thinking.
My Mother may have only paid a small amount for her Neurologist, Medicare did pay the majority of the bills. Mom had a "share clause" (I do too) with her secondary.
If you are on straight Medicare, you should get a summary of why they did not pay a claim. Your supplimental will not pay if Medicare didn't. Was the Neurologist a Medicare Dr?. If not that is your problem, its an out of pocket cost. But you should have been made aware of this when you presented you insurance cards.
Are you on a Medicare Advantage? If so, this maybe your problem. Like said, some require the PCP to give you a referral to another Dr. MAs are contracted out by Medicare. They are suppose to cover parts A&B of Medicare. My daughter who was a Unit Manager, was always fighting with MAs in what they needed to cover and didn't.
I guess you have talked to the office since you say "they did attempt to file with the insurances". What reason did the doctors office say they were given for nonpayment? You should get a denial letter from Medicare or the MA if that is what you have. The reason for the denial is on the statement summary sent out.
If you are straight Medicare, call them and ask why the denial. If a MA, call them and ask why the denial. Until you know the denial, you can't do something about it.
I found this: "Medicare Part B covers 80% of your medically necessary neurological services and treatments, including telehealth options, outpatient therapy and durable medical equipment (DME) once you pay your $226 deductible in 2023. Part B covers diagnostic and preventative testing, including brain scans and laboratory tests."
Have you received a denial of services notice from Medicare? Find out what happened (by first calling the doctor's insurance/billing dept.) and APPEAL the decision.
If you have a Medicare Advantage plan, you may have needed a referral/prior authorization from your primary physician.
It is my understanding (correct me if I am wrong) that a Medicare Advantage Plan is required to provide the same allowed coverage that Medicare provides.
But I am not an expert, these are things I have read on AgingCare and just wanted to start you off thinking by passing on the information.
Please don't shoot the messenger. I am having just as much trouble getting medical care as the next person. An MRI brain scan was ordered by my husband's doctor, and denied by insurance. Now, he will need to see a neurologist, (which will also need to be a referral by his PCP-primary Care Physician.)
When my daughter was in 8th grade they wanted her to have an MMR booster. My insurance did not pay for Dr visits. My daughter thought she broke her ankle so DH took her to the doctor. He was charged $40 for the visit, which he paid. (This was 1998) I got a statement from BC saying that they covered the visit because it was an accident, $35. I figured I'd just leave that as a credit at the Drs and use it the next time there was a Dr. visit. I called to set up the booster, told the cost, and then I asked about the $35 credit. There was no credit on the books. Well I have proof. Need to talk to the billing clerk. Clerk told me she needed to research. When she started giving me the run around I wrote the doctor, no call from him. I then called BC. One of the problems with the billing clerk was she was only going to refund me $35. I said no, $40. BC paid her what she was owed under contract she owed me $40. BC agreed with me called the billing clerk and told her to refund the $40 DH had paid. I got the refund of $40 in a money order not the Drs check. Found out later the clerk was let go because she was stealing. She fooled with the wrong person because I worked at accounts receivable and collections. My background has helped me sort out mistakes billing departments have made.
Sometimes the problem is more easy to resolve with a few phone calls, like you did. And not putting it off for later is also a good idea.
Other times, as has been my experience, they just do not know the answers, (doctor's staff, insurance staff), and then they lie. Spending more than a few hours in one day on these issues can be extremely stressful, and they are not listening. I don't know every detail of their rules, but I know enough to understand when they are wrong. And if they are not wrong, they should explain why. Result: I have given up
way too many times.
So, good for you!
You need to see the statement from Medicare showing you why they did not pay or ur MA. I am on straight Medicare. I had a Mammogram in 2021. I have a Medicare statement/summary telling me that part of the service preformed was not covered by Medicare. Also, I was not responsible for the charge if they tried to bill me.
So as I said, knowing if your straight Medicare or a Medicare Advantage is important.
I love those explanation of benefits (now called Medicare Summary?) that state we are not responsible for the denied charges.
Means they are enrolled as a Medicare provider, bill Medicare, and accept payment in full from Medicare. In full means whatever Medicare has allowed and approved. They cannot seek payment from the patient because they are under a Medicare contract with Medicare.
Type II: A doctor can bill Medicare for you as a courtesy, but expect you to pay a difference between what Medicare paid and the bill. This is called a 'limiting charge', up to about 15% in many states. In other words, this doctor does not accept Medicare assignment as payment in full. The doctor must inform you, and likely did in advance on the papers you signed to receive care at the office.
Type III: The doctor may have 'Opted Out' of Medicare altogether (No Medicare contract), and cannot bill Medicare, and Medicare will not reimburse you to be seen by this doctor.
Type IV: The doctor's billing staff is unaware they are billing for charges that are not due from the patient.
Checking it out falls on the patient.
If you are on straight Medicare, you should get a summary of why they did not pay a claim. Your supplimental will not pay if Medicare didn't. Was the Neurologist a Medicare Dr?. If not that is your problem, its an out of pocket cost. But you should have been made aware of this when you presented you insurance cards.
Are you on a Medicare Advantage? If so, this maybe your problem. Like said, some require the PCP to give you a referral to another Dr. MAs are contracted out by Medicare. They are suppose to cover parts A&B of Medicare. My daughter who was a Unit Manager, was always fighting with MAs in what they needed to cover and didn't.
I guess you have talked to the office since you say "they did attempt to file with the insurances". What reason did the doctors office say they were given for nonpayment? You should get a denial letter from Medicare or the MA if that is what you have. The reason for the denial is on the statement summary sent out.
If you are straight Medicare, call them and ask why the denial. If a MA, call them and ask why the denial. Until you know the denial, you can't do something about it.
"Medicare Part B covers 80% of your medically necessary neurological services and treatments, including telehealth options, outpatient therapy and durable medical equipment (DME) once you pay your $226 deductible in 2023. Part B covers diagnostic and preventative testing, including brain scans and laboratory tests."
Have you received a denial of services notice from Medicare? Find out what happened (by first calling the doctor's insurance/billing dept.) and APPEAL the decision.
If you have a Medicare Advantage plan, you may have needed a referral/prior authorization from your primary physician.
It is my understanding (correct me if I am wrong) that a Medicare Advantage Plan is required to provide the same allowed coverage that Medicare provides.
But I am not an expert, these are things I have read on AgingCare and just wanted to start you off thinking by passing on the information.
Please don't shoot the messenger. I am having just as much trouble getting medical care as the next person. An MRI brain scan was ordered by my husband's doctor, and denied by insurance. Now, he will need to see a neurologist, (which will also need to be a referral by his PCP-primary Care Physician.)