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Except in rare cases, your Medicare claims will be sent directly from your Medicare providers to Medicare. Payments will then be sent directly from Medicare to your Medicare providers according to the Medicare reimbursement rates. This is often accomplished electronically. Only under very unusual circumstances will Medicare reimburse a Medicare patient directly for expenses related to his or her medical care.
The Way Medicare Reimbursement Rates Work
Medicare reimbursements do not apply to Medicare deductions or Medicare premiums. They only apply to charges directly related to medical care. Medicare reimbursement rates are set by federal legislation, and govern how much a provider or supplier will receive from Medicare for Medicare claims.
If you have Original Medicare, your Medicare providers and medical suppliers are required by law to submit Medicare claims related to your medical care directly to Medicare. These claims are often filed electronically, and payment is made according to the Medicare reimbursement rates listed in the Medicare fee schedule.
If you have a Medicare Advantage Plan, your plan provider (such as Blue Cross Blue Shield or United Healthcare) does not have to file a Medicare claim, because Medicare pays the insurance company a set amount each month toward your medical expenses. Your doctor or supplier would then file a claim directly with your plan provider. Different Medicare Advantage Plans have slightly different Medicare reimbursement rates for the same services. This partly explains how some Medicare Advantage Plans can have more in-network providers than other plans in the same area. Doctors may choose to accept the plans that offer higher payments.
In rare cases, you may have to file a claim for reimbursement. This would only happen if you received services from a provider who did not accept Medicare assignment.
How assignment works: If a provider accepts Medicare assignment, it means the provider is a participating contractor with Medicare and has agreed to accept the approved Medicare reimbursement rates as payment in full for Medicare claims. This means that if the approved Medicare reimbursement rate for a mammogram is $100, then a provider who accepts assignment will be required to accept $100 as payment in full for the service, even if his or her normal billing rate is $115. You would still be responsible for your portion of the fee (usually determined by your coinsurance, if your yearly deductible has already been met). However, because the provider accepts payment according to the Medicare reimbursement rates, you cannot be charged for the extra $15 not paid by Medicare.
If you received medical care from a provider who did not accept Medicare assignment, you may have been required to pay for the entire service up front. If this was the case, you may be eligible to file a claim for reimbursement. Your claim will be governed according to the Medicare reimbursement rates, even if your bill from the provider was more than the approved Medicare amount.
How to File a Claim
If you do need to file a Medicare claim, you will have to complete a form entitled "Patient's Request for Medical Payment," and send the completed form along with an itemized bill from your provider to the correct department in your state. You will be required to describe the reasons why you received medical care from the medical provider on the request form and to specify whether the illness or injury is related to a work incident. You will also be required to include information about any other insurance you may have, including insurance coverage through your employer or through your spouse's employer.
The itemized bill must list the following information:
- he date of service
- The place of service (doctor's office, hospital, patient's home, etc.)
- Description of each surgical or medical service or supply furnished
- Charge for each service
- Name and address of the doctor or supplier who provided the service to you
- Diagnosis (unless you have supplied a good description of your illness on the form itself)
Medicare claims are always paid according to the Medicare reimbursement rates listed in the Medicare fee schedule, even if the claims are submitted by individual Medicare claims. As such, you may receive less than you were required to pay. (For help filing Medicare claims, visit the Medicare.gov website.)
There are time limits for filing Medicare claims. If you wish to seek reimbursement for Medicare costs that you paid up front, you will be required to submit your claim within one calendar year of the date the service was provided. Any claims submitted more than a year after the service was provided will likely be denied.
Medicare Advantage Plans
Medicare Advantage Plans do not file claims directly with Medicare. If you are enrolled in any of the Medicare Advantage Plans you may be required to pay the full amount of any services you obtain from providers who are outside of your network. If you have questions about Medicare reimbursement rates and a Medicare cost, and you are enrolled in a Medicare Advantage Plan, you should contact your plan provider directly.