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How does a doctor’s participation in Medicare affect reimbursement?
Medicare reimbursement refers to the payments that hospitals and physicians receive in return for services rendered to Medicare beneficiaries. The reimbursement rates for these services are set by Medicare, and are typically less than the amount billed or the amount that a private insurance company would pay.
Medicare eligibility, enrollment and coverage options
Learn about your coverage options, how to sign up for Medicare or change your plan, and coverage costs you can expect
Important Medicare enrollment dates
Enrollment dates for Medicare are critical. Missing an enrollment date could cost you higher premiums down the line — or it could cost you coverage entirely.
Q: How do I file a healthcare claim with Medicare or my insurer?
A: Medicare beneficiaries occasionally have to submit their own healthcare claims instead of relying on a provider to submit them. Here’s what you need to know about filing a Medicare claim.
A claim asks Medicare or your insurer to pay for your medical care. Claims are submitted to Medicare after you see a doctor or are treated in a hospital. If you have a Medicare Advantage or Part D plan, your insurer will process claims on Medicare’s behalf.
Your healthcare provider will usually file claims for you. You should never have to submit claims for Part A services such as hospital, skilled nursing facility (SNF) or hospice care. When it comes to outpatient care, some providers will not file claims. This can happen if you have Original Medicare and see a non-participating provider, or if you have Medicare Advantage and visit an out-of-network doctor.
Beneficiaries can submit their own claims for certain services when a provider won’t file a claim. However, you cannot file a claim with Original Medicare for diabetic test strips, Part B drugs, or equipment paid for under the DMEPOS Competitive Bidding Program. Your pharmacy or medical supplier must bill Medicare directly for these items.
Original Medicare has both participating and non-participating providers. Participating providers accept Medicare’s reimbursement plus your coinsurance as full payment, and have agreed to always bill Medicare for your care. Non-participating providers can charge you up to 115 percent of Medicare’s rate (in most states) and don’t have to file claims with Medicare, although some choose to do so. This means you may have to submit your own healthcare claim if you see a non-participating provider. (A small number of clinicians are opt-out providers. Medicare will never pay for care from these providers, even if you file a claim.)
Original Medicare claims have to be submitted within 12 months of when you received care. Medicare Advantage plans have different time limits for when you have to submit claims, and these time limits are shorter than Original Medicare. Contact your Advantage plan to find out its time limit for submitting claims.
Before receiving care, ask your provider’s office whether they will submit your bill to Original Medicare. While they aren’t required to do so, some non-participating providers will still file your claims with Medicare.
The same situation applies for Medicare Advantage enrollees who see out-of-network providers. These providers don’t have to file claims with your Advantage plan, but may choose to do so. (Medicare Advantage enrollees can see out-of-network providers for routine care only if their plan includes out-of-network coverage, but all Advantage enrollees have coverage for out-of-network urgent and emergency room care. You may have to file your own claims when you receive any of these types of out-of-network care.)
If you have Original Medicare and a participating provider refuses to submit a claim, you can file a complaint with 1-800-MEDICARE. Regardless of whether or not the provider is required to file claims, you can submit the healthcare claims yourself. You can file an Original Medicare claim by sending a Beneficiary Request for Medical Payment form and the provider’s bill or invoice to your regional Medicare Administrative Contractor (Here is a list of these broken down by state). Keep copies of everything you submit.
(Original Medicare providers have to give you an advance beneficiary notice (ABN), Home Health Advance Beneficiary Notice, or Skilled Nursing Advance Beneficiary Notice if they believe Medicare will not cover your care. Providers normally will not bill Medicare after they issue an ABN.
You have the right to demand bill, which is when you demand that the provider or facility submit a claim to Medicare for your care. In order to demand bill, you must sign the ABN and agree to pay the charges if Medicare denies coverage. Demand billing can be used to generate a formal Medicare coverage denial, which gives you further appeal rights.)
If you have Medicare Advantage, providers in the plan’s network have to bill your insurer for your care. As mentioned above, you may have to submit your own claims if you go out-of-network.
If you decide to file a claim yourself, first contact your insurer for its claims mailing address and any forms to include with your claim. (You’ll send Advantage plan claims to your insurer rather than to Medicare.) Because Advantage plans have different time limits for filing claims than Original Medicare, be sure to follow your insurer’s rules to avoid a denial.
Original Medicare will automatically send your claims to most Medigap insurers for secondary payment, but some Medigap insurers require plan holders to manually file claims. If you have to submit your own Medigap claim, you’ll need to at least send the insurer a Medicare summary notice (MSN) showing the payment Medicare made, and you may need to provide other documentation, such as an invoice or receipt. You don’t have to submit an MSN when filing claims for Medigap services that aren’t covered by Original Medicare (e.g. emergency care while traveling internationally). Contact your Medigap insurer if you have questions about Medigap claims.
You may have already paid in full for your care when you filed your claim. Be sure to note that you’ve paid on your submission, so Medicare or your insurer reimburses you rather than your provider. Keep copies of everything you submit.
Medicare Part D plans contract with pharmacies where you can fill your prescriptions. Both preferred and non-preferred pharmacies can bill your Part D insurer, although your cost will be lower if you use a preferred pharmacy. If you have to fill medications at a pharmacy outside your plan’s network because of an emergency, you may be able to receive partial reimbursement by submitting your receipt and supporting documentation to your Part D insurer. Contact your insurer for instructions if you need to file an out-of-network claim.
You may also have to file a Part D claim if you receive medications while hospitalized that aren’t reimbursed by Medicare or your Medicare Advantage plan’s payment for your care. Whether you need to submit the claim yourself depends on whether the hospital’s pharmacy has a contract with your Part D plan.
Original Medicare beneficiaries should receive an MSN every three months detailing their recent Medicare claims. Medicare Advantage and Part D enrollees receive Explanation of Benefits (EOB) statements after receiving care. Review all your statements to ensure claims are being filed and processed in a timely manner.
You can call 1-800-MEDICARE or your insurer to check on your claims. If you have Original Medicare, you can check claims status at MyMedicare.gov. Medicare Advantage and Part D plans also have online portals where you can view claims activity.
Many Medicare beneficiaries also qualify for Medicaid due to having limited incomes and resources. Medicaid pays for Medicare co-pays, deductibles and coinsurance for enrollees who see providers that accept both Medicare and Medicaid.
Show your health care provider your Medicare and Medicaid I.D. cards when you check in for your office visit. You should also show the provider your Medicaid managed care plan card (if you have one).
Read more here about Medicaid benefits (i.e., Medicare premium assistance and long-term care) for Medicare enrollees.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including as an associate at Sachs Policy Group, where he worked with insurer, hospital and technology clients.